Provider Demographics
NPI:1740635705
Name:BURTON, ETHEL MAE
Entity type:Individual
Prefix:MISS
First Name:ETHEL
Middle Name:MAE
Last Name:BURTON
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 1:3607 PENN DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-3656
Mailing Address - Country:US
Mailing Address - Phone:919-598-5191
Mailing Address - Fax:
Practice Address - Street 1:3607 PENN DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-3656
Practice Address - Country:US
Practice Address - Phone:919-598-5191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32001509171M00000X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator