Provider Demographics
NPI:1467542795
Name:BURNETTE, MARY MICHELE (PH D)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MICHELE
Last Name:BURNETTE
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:MICHELE
Other - Last Name:BURNETTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PH D
Mailing Address - Street 1:1898 CALHOUN ST
Mailing Address - Street 2:#5 RAINBOW ROW
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2612
Mailing Address - Country:US
Mailing Address - Phone:803-233-9175
Mailing Address - Fax:803-233-9177
Practice Address - Street 1:1898 CALHOUN ST
Practice Address - Street 2:#5 RAINBOW ROW
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2612
Practice Address - Country:US
Practice Address - Phone:803-233-9175
Practice Address - Fax:803-233-9177
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC887103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist