Provider Demographics
NPI:1922709559
Name:BURNETTE, CAROLYN BLAIR (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:BLAIR
Last Name:BURNETTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 WEST ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48915-1127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 WEST ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48915-1127
Practice Address - Country:US
Practice Address - Phone:615-308-4769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301019260103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling