Provider Demographics
NPI:1992854483
Name:J. RANDOLPH BURNHAM PH.D.,P.C.
Entity Type:Organization
Organization Name:J. RANDOLPH BURNHAM PH.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J. RANDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:203-227-7199
Mailing Address - Street 1:18 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4710
Mailing Address - Country:US
Mailing Address - Phone:203-227-7199
Mailing Address - Fax:
Practice Address - Street 1:18 KINGS HWY S
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4710
Practice Address - Country:US
Practice Address - Phone:203-227-7199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT464103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty