Provider Demographics
NPI:1437638624
Name:BURDETTE, CARLA MICHELLE
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:MICHELLE
Last Name:BURDETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:MICHELLE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1805 ESIC DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3945
Mailing Address - Country:US
Mailing Address - Phone:618-973-6930
Mailing Address - Fax:
Practice Address - Street 1:1805 ESIC DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3945
Practice Address - Country:US
Practice Address - Phone:618-973-6930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1815705103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool