Provider Demographics
NPI:1790201127
Name:BURNETT, SIDNEY J (MOTR/L)
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:J
Last Name:BURNETT
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-4007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 E 12TH ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-4007
Practice Address - Country:US
Practice Address - Phone:307-235-5097
Practice Address - Fax:307-473-1440
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOT-1283225X00000X
WYOTR-1283225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist