Provider Demographics
NPI:1205092632
Name:BURT, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BURT
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 1:5319 S. LEWIS
Mailing Address - Street 2:STE 219
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105
Mailing Address - Country:US
Mailing Address - Phone:918-832-7763
Mailing Address - Fax:918-292-8250
Practice Address - Street 1:5319 S. LEWIS
Practice Address - Street 2:STE 219
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105
Practice Address - Country:US
Practice Address - Phone:918-832-7763
Practice Address - Fax:918-292-8250
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)