1104269356 NPI number — TANA MARGUERITE BURNETT MA, BCBA

Table of content: TANA MARGUERITE BURNETT MA, BCBA (NPI 1104269356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104269356 NPI number — TANA MARGUERITE BURNETT MA, BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURNETT
Provider First Name:
TANA
Provider Middle Name:
MARGUERITE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUNDBERG
Provider Other First Name:
TANA
Provider Other Middle Name:
MARGUERITE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, BCBA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104269356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10615 PERRIN BEITEL RD
Provider Second Line Business Mailing Address:
SUITE # 801
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78217-3138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-657-7400
Provider Business Mailing Address Fax Number:
888-506-2589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10615 PERRIN BEITEL RD
Provider Second Line Business Practice Location Address:
SUITE # 801
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78217-3138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-657-7400
Provider Business Practice Location Address Fax Number:
888-506-2589
Provider Enumeration Date:
04/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-13-12931 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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