Provider Demographics
NPI:1043878408
Name:BURNHAM, COSSETTE (DPT, PT)
Entity Type:Individual
Prefix:
First Name:COSSETTE
Middle Name:
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:DPT, PT
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 8467
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-8467
Mailing Address - Country:US
Mailing Address - Phone:406-439-8035
Mailing Address - Fax:
Practice Address - Street 1:FOUR PINES PHYSICAL THERAPY
Practice Address - Street 2:1090 S HWY 89
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-18692251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic