Provider Demographics
NPI:1144558156
Name:BURNETT, MALLORY HELEN (MA LPCC)
Entity type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:HELEN
Last Name:BURNETT
Suffix:
Gender:F
Credentials:MA LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 DESERT WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-7530
Mailing Address - Country:US
Mailing Address - Phone:505-717-9552
Mailing Address - Fax:505-369-1121
Practice Address - Street 1:2469 CORRALES ROAD N.W.
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-7530
Practice Address - Country:US
Practice Address - Phone:505-717-9552
Practice Address - Fax:505-369-1121
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0127561101YM0800X
NMLPCC0150041101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM76288251Medicaid