Provider Demographics
NPI:1003105347
Name:BURNETT, TIMOTHY (PSYD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BURNETT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 S 1220 W
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-2370
Mailing Address - Country:US
Mailing Address - Phone:801-739-3873
Mailing Address - Fax:
Practice Address - Street 1:BROOKE ARMY MEDICAL CENTER
Practice Address - Street 2:3551 ROGER BROOKE DRIVE
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:801-739-3873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
WAPY60675544103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program