Provider Demographics
NPI:1972691954
Name:BURNS, CAROLYN LORENE (LMFT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:LORENE
Last Name:BURNS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:INTEGRATIVE
Other - Middle Name:THERAPY
Other - Last Name:LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:209 VUELTA ROBLE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501
Mailing Address - Country:US
Mailing Address - Phone:505-795-8190
Mailing Address - Fax:
Practice Address - Street 1:128 GRANT AVE
Practice Address - Street 2:STE 218
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2031
Practice Address - Country:US
Practice Address - Phone:505-795-8190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0103251106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80473024Medicaid