Provider Demographics
NPI:1619379310
Name:BURT, NATHANIEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:
Last Name:BURT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26167 MILLER BAY RD NE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-9404
Mailing Address - Country:US
Mailing Address - Phone:360-860-2321
Mailing Address - Fax:
Practice Address - Street 1:3420 NE SAND HILL RD
Practice Address - Street 2:
Practice Address - City:BELFAIR
Practice Address - State:WA
Practice Address - Zip Code:98528-9007
Practice Address - Country:US
Practice Address - Phone:360-277-2414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60287726103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical