Provider Demographics
NPI:1699215574
Name:BURTNESS, ROXANN (LAC)
Entity Type:Individual
Prefix:
First Name:ROXANN
Middle Name:
Last Name:BURTNESS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2311
Mailing Address - Country:US
Mailing Address - Phone:701-451-4900
Mailing Address - Fax:651-925-0057
Practice Address - Street 1:2701 12TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8753
Practice Address - Country:US
Practice Address - Phone:701-451-4900
Practice Address - Fax:651-925-0057
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1805101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)