Provider Demographics
NPI:1609969963
Name:BURTON, MARK SCOTT
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SCOTT
Last Name:BURTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:SCOTT
Other - Last Name:BURTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:21 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3703
Mailing Address - Country:US
Mailing Address - Phone:978-470-4975
Mailing Address - Fax:978-470-4607
Practice Address - Street 1:21 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3703
Practice Address - Country:US
Practice Address - Phone:978-470-4975
Practice Address - Fax:978-470-4607
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10262291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABU P23205Medicare ID - Type UnspecifiedMEDICARE PROVIDER