Provider Demographics
NPI:1760664262
Name:BURNS, ROBERT JOHN
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:BURNS
Suffix:
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 1300
Mailing Address - Street 2:
Mailing Address - City:NEW CUMBERLAND
Mailing Address - State:WV
Mailing Address - Zip Code:26047-1300
Mailing Address - Country:US
Mailing Address - Phone:304-564-3411
Mailing Address - Fax:304-564-3990
Practice Address - Street 1:195 GOLDEN BEAR DR
Practice Address - Street 2:
Practice Address - City:NEW CUMBERLAND
Practice Address - State:WV
Practice Address - Zip Code:26047-1672
Practice Address - Country:US
Practice Address - Phone:304-564-3411
Practice Address - Fax:304-564-3990
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV6950103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9201060000Medicaid