Provider Demographics
NPI:1457407447
Name:BURNETT, GEORGE AURTHUR JR (MS)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:AURTHUR
Last Name:BURNETT
Suffix:JR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 363
Mailing Address - Street 2:
Mailing Address - City:ELEPHANT BUTTE
Mailing Address - State:NM
Mailing Address - Zip Code:87935-0363
Mailing Address - Country:US
Mailing Address - Phone:505-740-2118
Mailing Address - Fax:
Practice Address - Street 1:180 N DATE ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-2824
Practice Address - Country:US
Practice Address - Phone:505-740-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2503235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2503OtherSTATE SLP LICENSE
NM72832Medicaid