Provider Demographics
NPI:1417005554
Name:BURNHAM, J. RANDOLPH (PHD)
Entity Type:Individual
Prefix:
First Name:J. RANDOLPH
Middle Name:
Last Name:BURNHAM
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 1:18 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4710
Mailing Address - Country:US
Mailing Address - Phone:203-227-7199
Mailing Address - Fax:
Practice Address - Street 1:18 KINGS HWY S
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4710
Practice Address - Country:US
Practice Address - Phone:203-227-7199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1376103T00000X
CT464103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical