Provider Demographics
NPI:1689165391
Name:BURNETT, MALLORI J (MED)
Entity Type:Individual
Prefix:
First Name:MALLORI
Middle Name:J
Last Name:BURNETT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12743 5875 RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81403-8393
Mailing Address - Country:US
Mailing Address - Phone:970-765-5284
Mailing Address - Fax:
Practice Address - Street 1:18 N UNCOMPAHGRE AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3986
Practice Address - Country:US
Practice Address - Phone:970-765-8428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-17-26264103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst