Provider Demographics
NPI:1134267016
Name:BURNETT, GARY MAIN (MA, LPC, LMSW)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:MAIN
Last Name:BURNETT
Suffix:
Gender:M
Credentials:MA, LPC, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5769 LONLOH PINES CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4088
Mailing Address - Country:US
Mailing Address - Phone:248-618-7944
Mailing Address - Fax:
Practice Address - Street 1:46360 GRATIOT AVE.
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051
Practice Address - Country:US
Practice Address - Phone:586-948-0224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401001100101YM0800X
MI68010211691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical