Provider Demographics
NPI:1043502727
Name:BURNETT, ELLEN (LPA)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BURNETT
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2161
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-7161
Mailing Address - Country:US
Mailing Address - Phone:252-537-6164
Mailing Address - Fax:252-537-9199
Practice Address - Street 1:600 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-2604
Practice Address - Country:US
Practice Address - Phone:252-537-6164
Practice Address - Fax:252-537-9199
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0693103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0693OtherNC PSYCHOLOGY BOARD