Provider Demographics
NPI:1417567314
Name:BURNETT, MARY KATHERINE
Entity Type:Individual
Prefix:
First Name:MARY KATHERINE
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 1:862 NOTTINGHAM RD APT 2S
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:862 NOTTINGHAM RD APT 2S
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230-1755
Practice Address - Country:US
Practice Address - Phone:313-613-9165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty