Provider Demographics
NPI:1972990158
Name:BURDEN, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BURDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CHEVY CHASE RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2514
Mailing Address - Country:US
Mailing Address - Phone:508-868-1580
Mailing Address - Fax:
Practice Address - Street 1:19 CHEVY CHASE RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2514
Practice Address - Country:US
Practice Address - Phone:508-868-1580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103K00000K103K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst