Provider Demographics
NPI:1366489684
Name:BURNS, JOHN W (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:BURNS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3471 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064-3037
Mailing Address - Country:US
Mailing Address - Phone:847-473-4357
Mailing Address - Fax:847-578-8671
Practice Address - Street 1:3471 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3037
Practice Address - Country:US
Practice Address - Phone:847-473-4357
Practice Address - Fax:847-578-8671
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005317103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK13194Medicare ID - Type Unspecified
ILP75999Medicare UPIN