Provider Demographics
NPI:1790880839
Name:BURT, JOHN W (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:BURT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:255 LINDEN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4435
Mailing Address - Country:US
Mailing Address - Phone:970-482-4334
Mailing Address - Fax:970-407-1339
Practice Address - Street 1:255 LINDEN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4435
Practice Address - Country:US
Practice Address - Phone:970-482-4334
Practice Address - Fax:970-407-1339
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO2055103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07020555Medicaid
CO67776Medicare ID - Type Unspecified