Provider Demographics
NPI:1528403243
Name:BURI-BACA, KATHLEEN JO (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JO
Last Name:BURI-BACA
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:RIMROCK
Mailing Address - State:AZ
Mailing Address - Zip Code:86335-0230
Mailing Address - Country:US
Mailing Address - Phone:928-567-1322
Mailing Address - Fax:928-567-1323
Practice Address - Street 1:3095 CORONADO TRAIL
Practice Address - Street 2:
Practice Address - City:RIMROCK
Practice Address - State:AZ
Practice Address - Zip Code:86335-0230
Practice Address - Country:US
Practice Address - Phone:928-567-1322
Practice Address - Fax:928-567-1323
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-14540101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional