Provider Demographics
NPI:1710231352
Name:BURNS, JOHN DUANE SR
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DUANE
Last Name:BURNS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 404
Mailing Address - Street 2:
Mailing Address - City:LAME DEER
Mailing Address - State:MT
Mailing Address - Zip Code:59043-0404
Mailing Address - Country:US
Mailing Address - Phone:406-477-6381
Mailing Address - Fax:406-477-6727
Practice Address - Street 1:100 EAGLE FEATHERS DRIVE
Practice Address - Street 2:
Practice Address - City:LAME DEER
Practice Address - State:MT
Practice Address - Zip Code:59043
Practice Address - Country:US
Practice Address - Phone:406-477-6381
Practice Address - Fax:406-477-6727
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11-118101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11-118OtherSOUTHWEST CERTIFICATION BOARD