Provider Demographics
NPI:1891812228
Name:BURNHAM, VIOLET MARIE (MA)
Entity Type:Individual
Prefix:MS
First Name:VIOLET
Middle Name:MARIE
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:MA
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 70
Mailing Address - Street 2:
Mailing Address - City:KALTAG
Mailing Address - State:AK
Mailing Address - Zip Code:99748-0070
Mailing Address - Country:US
Mailing Address - Phone:907-534-2220
Mailing Address - Fax:907-534-2236
Practice Address - Street 1:400 BLACKBERRY LANE
Practice Address - Street 2:
Practice Address - City:KALTAG
Practice Address - State:AK
Practice Address - Zip Code:99748-0008
Practice Address - Country:US
Practice Address - Phone:907-534-2220
Practice Address - Fax:907-534-2236
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKM.A.251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health