Provider Demographics
NPI:1184319519
Name:BURNETT, TIESHA
Entity type:Individual
Prefix:
First Name:TIESHA
Middle Name:
Last Name:BURNETT
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 1:205 N MICHIGAN AVE STE 810
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-5902
Mailing Address - Country:US
Mailing Address - Phone:312-637-0230
Mailing Address - Fax:
Practice Address - Street 1:1515 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1250
Practice Address - Country:US
Practice Address - Phone:888-780-0006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health