Provider Demographics
NPI:1093468233
Name:BURNETTE, KEON (RBT)
Entity Type:Individual
Prefix:
First Name:KEON
Middle Name:
Last Name:BURNETTE
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 WHITTLESEY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-9211
Mailing Address - Country:US
Mailing Address - Phone:706-221-9629
Mailing Address - Fax:
Practice Address - Street 1:1921 WHITTLESEY RD STE 400
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-9211
Practice Address - Country:US
Practice Address - Phone:706-221-9629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21194654106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician