Basic Information
| Provider Information | |||||||||
| NPI: | 1033552955 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURT | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 938 | ||||||||
| Address2: | |||||||||
| City: | ROWLETT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750300938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640880 | ||||||||
| Practice Location | |||||||||
| Address1: | 3091 SPRING BRANCH DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ELM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750682990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2013 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 140186 | TX | N | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant | 246ZC0007X | SA00676 | TX | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.