Provider Demographics
NPI:1902319312
Name:BURNETT, ANGELA (MA, NCC, LCMHC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BURNETT
Suffix:
Gender:F
Credentials:MA, NCC, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2117 POSSUM TROT RD
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6652
Mailing Address - Country:US
Mailing Address - Phone:336-392-2794
Mailing Address - Fax:
Practice Address - Street 1:2117 POSSUM TROT RD
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6652
Practice Address - Country:US
Practice Address - Phone:336-392-2794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12866101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC$$$$$$$$$OtherPRIVATE PAY