Provider Demographics
NPI:1134870421
Name:BURNETTE, VERONICA (OWNER ADULT MEDICAL)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:BURNETTE
Suffix:
Gender:F
Credentials:OWNER ADULT MEDICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7806 ROLLING VISTA CT
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-3643
Mailing Address - Country:US
Mailing Address - Phone:443-983-9918
Mailing Address - Fax:
Practice Address - Street 1:1500 COUNTRY RIDGE LN
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:MD
Practice Address - Zip Code:21221-3906
Practice Address - Country:US
Practice Address - Phone:410-871-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR135126103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities