Provider Demographics
NPI:1851312581
Name:BURNETT, TOM WILLIAM I (LAC)
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:WILLIAM
Last Name:BURNETT
Suffix:I
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4781 S GRAND ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-6403
Mailing Address - Country:US
Mailing Address - Phone:318-362-5430
Mailing Address - Fax:318-362-5428
Practice Address - Street 1:4781 S GRAND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6403
Practice Address - Country:US
Practice Address - Phone:318-362-5430
Practice Address - Fax:318-362-5428
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA791101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)