Provider Demographics
NPI:1548812696
Name:BURNHAM, CARRIE S
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:S
Last Name:BURNHAM
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 1:17 2ND ST E STE 212
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-4500
Mailing Address - Country:US
Mailing Address - Phone:406-270-7964
Mailing Address - Fax:
Practice Address - Street 1:17 2ND ST E STE 212
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4500
Practice Address - Country:US
Practice Address - Phone:406-270-7964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-27102101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional