Provider Demographics
NPI:1003852336
Name:BURT, PHYLLIS (MA CCCA)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:
Last Name:BURT
Suffix:
Gender:F
Credentials:MA CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-6501
Mailing Address - Country:US
Mailing Address - Phone:707-938-3611
Mailing Address - Fax:408-356-1988
Practice Address - Street 1:511 3RD ST W
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-6501
Practice Address - Country:US
Practice Address - Phone:707-938-3610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA1018237600000X
CAAU289231H00000X, 237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0002829Medicaid
CAAU0002829Medicaid