Provider Demographics
NPI:1629411590
Name:BURNETT, BERYLE
Entity Type:Individual
Prefix:
First Name:BERYLE
Middle Name:
Last Name:BURNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 WESLEY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1677
Mailing Address - Country:US
Mailing Address - Phone:704-222-9883
Mailing Address - Fax:404-893-6445
Practice Address - Street 1:1225 CAPITOL AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-2707
Practice Address - Country:US
Practice Address - Phone:404-612-1408
Practice Address - Fax:404-893-6445
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0046104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker