Provider Demographics
NPI:1558505347
Name:BURT, TERESA (LPC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BURT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 W ROADRUNNER DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286
Mailing Address - Country:US
Mailing Address - Phone:480-219-9341
Mailing Address - Fax:
Practice Address - Street 1:160 W ROADRUNNER DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286
Practice Address - Country:US
Practice Address - Phone:480-219-9341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12757101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional