Provider Demographics
NPI:1396026274
Name:BURT, JOHN AMOS
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:AMOS
Last Name:BURT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-0131
Mailing Address - Country:US
Mailing Address - Phone:209-534-5155
Mailing Address - Fax:
Practice Address - Street 1:17000 S HARLAN RD
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-8738
Practice Address - Country:US
Practice Address - Phone:209-647-7609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT140197106H00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist