Provider Demographics
NPI:1154487882
Name:BURNETT, CONNIE (LPC)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:BURNETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73495 HIGHWAY 101
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-7800
Mailing Address - Country:US
Mailing Address - Phone:406-925-1313
Mailing Address - Fax:
Practice Address - Street 1:375 PARK AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2244
Practice Address - Country:US
Practice Address - Phone:406-925-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1158101YP2500X
ORC4806101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000741910OtherBLUE CROSS BLUE SHIELD
MT256542Medicaid
MT0255374Medicaid