Provider Demographics
NPI:1033382726
Name:BURRELL, DAVEY
Entity Type:Individual
Prefix:
First Name:DAVEY
Middle Name:
Last Name:BURRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 GARRETT WAY
Mailing Address - Street 2:STE. 1
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5100
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:208-236-6695
Practice Address - Street 1:2055 GARRETT WAY
Practice Address - Street 2:STE. 1
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5100
Practice Address - Country:US
Practice Address - Phone:208-236-1600
Practice Address - Fax:208-236-6695
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW26555101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health