Provider Demographics
NPI:1508660085
Name:PRACHITTHAM-BURKETT, ANNELISE K
Entity type:Individual
Prefix:
First Name:ANNELISE
Middle Name:K
Last Name:PRACHITTHAM-BURKETT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 SHAMERAN ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-4110
Mailing Address - Country:US
Mailing Address - Phone:209-871-3202
Mailing Address - Fax:
Practice Address - Street 1:5637 N PERSHING AVE STE B7
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4955
Practice Address - Country:US
Practice Address - Phone:408-439-6308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician