Provider Demographics
NPI:1952487068
Name:BURNETT, EZEKIEL W (LCSW)
Entity Type:Individual
Prefix:
First Name:EZEKIEL
Middle Name:W
Last Name:BURNETT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 E 700 S # 11-15
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-3432
Mailing Address - Country:US
Mailing Address - Phone:435-725-6300
Mailing Address - Fax:
Practice Address - Street 1:285 W 800 S
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-3707
Practice Address - Country:US
Practice Address - Phone:435-725-6300
Practice Address - Fax:435-725-6325
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5239057-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical