Provider Demographics
NPI:1528402195
Name:BURNETT, KACY
Entity Type:Individual
Prefix:
First Name:KACY
Middle Name:
Last Name:BURNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9211 N COUNCIL RD
Mailing Address - Street 2:APT 629
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-1345
Mailing Address - Country:US
Mailing Address - Phone:316-213-9068
Mailing Address - Fax:
Practice Address - Street 1:9211 N COUNCIL RD
Practice Address - Street 2:APT 629
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-1345
Practice Address - Country:US
Practice Address - Phone:316-213-9068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health