Provider Demographics
NPI:1164561437
Name:BURDETT, GLORIA L (MS, PMHCNS-BC)
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:L
Last Name:BURDETT
Suffix:
Gender:F
Credentials:MS, PMHCNS-BC
Other - Prefix:MS
Other - First Name:GLORIA
Other - Middle Name:E
Other - Last Name:SHAPIRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, APRN
Mailing Address - Street 1:37 FRIEND ST.
Mailing Address - Street 2:ELDER SERVICE PLAN OF THE NORTH SHORE
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902
Mailing Address - Country:US
Mailing Address - Phone:781-715-6608
Mailing Address - Fax:781-715-6699
Practice Address - Street 1:37 FRIEND ST.
Practice Address - Street 2:ELDER SERVICE PLAN OF THE NORTH SHORE
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902
Practice Address - Country:US
Practice Address - Phone:781-715-6608
Practice Address - Fax:781-715-6699
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH052943-23-08363LP0808X
NH052943-23363LP0808X
MARN100851364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHQ16020Medicare UPIN
NHBUN56016Medicare ID - Type Unspecified
NHRE3213Medicare ID - Type Unspecified