Provider Demographics
NPI:1174180384
Name:BURNETT, SUMMER
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:
Last Name:BURNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 LIBERTY LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-9432
Mailing Address - Country:US
Mailing Address - Phone:405-548-1029
Mailing Address - Fax:817-549-3172
Practice Address - Street 1:600 LIBERTY LN
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-9432
Practice Address - Country:US
Practice Address - Phone:405-548-1029
Practice Address - Fax:817-549-3172
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-19-83208106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician