Provider Demographics
NPI:1629258421
Name:BURNETT, STACY M (MSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:BURNETT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 MEDFORD ST.
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143
Mailing Address - Country:US
Mailing Address - Phone:617-629-3919
Mailing Address - Fax:617-629-4644
Practice Address - Street 1:61 MEDFORD ST.
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143
Practice Address - Country:US
Practice Address - Phone:617-629-3919
Practice Address - Fax:617-629-4644
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215035104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker