Provider Demographics
NPI:1215040092
Name:BURT, LORI J (LCSW)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:J
Last Name:BURT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:BURT
Other - Last Name:CHELETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:149 HART STREET
Mailing Address - Street 2:82 MDG/MENTAL HEALTH
Mailing Address - City:SHEPPARD AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76311
Mailing Address - Country:US
Mailing Address - Phone:940-676-6075
Mailing Address - Fax:
Practice Address - Street 1:149 HART STREET
Practice Address - Street 2:82 MDG/MENTAL HEALTH
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311
Practice Address - Country:US
Practice Address - Phone:940-676-6075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS226851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical