Provider Demographics
NPI:1003970997
Name:BURNETT, FREDERICK W JR (LCSW)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:W
Last Name:BURNETT
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WINDSOR PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-5809
Mailing Address - Country:US
Mailing Address - Phone:718-832-2104
Mailing Address - Fax:
Practice Address - Street 1:300 MERCER ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-6724
Practice Address - Country:US
Practice Address - Phone:718-208-7068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0150611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N16601Medicare ID - Type Unspecified