Provider Demographics
NPI:1023029253
Name:BURNSIDE, CAROLINE (LMFT, CHOM)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:BURNSIDE
Suffix:
Gender:F
Credentials:LMFT, CHOM
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 366
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946-0366
Mailing Address - Country:US
Mailing Address - Phone:530-432-6336
Mailing Address - Fax:530-432-6511
Practice Address - Street 1:10628 MELODY RD
Practice Address - Street 2:
Practice Address - City:BIG OAK VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95977-9537
Practice Address - Country:US
Practice Address - Phone:530-432-6336
Practice Address - Fax:530-432-6511
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT20803106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist