Basic Information
| Provider Information | |||||||||
| NPI: | 1538763263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNETT | ||||||||
| FirstName: | CHARI | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6021 FAIRMONT PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775054511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817692238 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6021 FAIRMONT PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775054511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817692238 | ||||||||
| FaxNumber: | 2817692164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2020 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 84098 | TX | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 825487029 | 05 | TX | MEDICAID |