Provider Demographics
NPI:1467893214
Name:BURNSIDE, THOMAS ROBERT (AAS, AAC, CDPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROBERT
Last Name:BURNSIDE
Suffix:
Gender:M
Credentials:AAS, AAC, CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9930 EVERGREEN WAY STE Z150
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-3889
Mailing Address - Country:US
Mailing Address - Phone:425-347-5121
Mailing Address - Fax:254-353-6425
Practice Address - Street 1:9930 EVERGREEN WAY STE Z150
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-3889
Practice Address - Country:US
Practice Address - Phone:425-347-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60397566101YM0800X, 101Y00000X
WACO60318881390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program