Provider Demographics
NPI:1558659565
Name:BURNETT, KEITHA JOAN (LCS,W,)
Entity type:Individual
Prefix:
First Name:KEITHA
Middle Name:JOAN
Last Name:BURNETT
Suffix:
Gender:F
Credentials:LCS,W,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3954 YOUNGFIELD ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-3865
Mailing Address - Country:US
Mailing Address - Phone:720-328-0569
Mailing Address - Fax:720-328-0769
Practice Address - Street 1:3954 YOUNGFIELD ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-3865
Practice Address - Country:US
Practice Address - Phone:720-328-0569
Practice Address - Fax:720-328-0769
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical