Provider Demographics
NPI:1023581196
Name:BURNSIDE, ATHENA M
Entity type:Individual
Prefix:MS
First Name:ATHENA
Middle Name:M
Last Name:BURNSIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 S EL CAMINO REAL STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2382
Mailing Address - Country:US
Mailing Address - Phone:650-578-8691
Mailing Address - Fax:
Practice Address - Street 1:2600 S EL CAMINO REAL STE 200
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2382
Practice Address - Country:US
Practice Address - Phone:650-372-4080
Practice Address - Fax:650-400-9662
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health