Provider Demographics
NPI:1053572669
Name:BURTLESS, DAVID (LPC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:BURTLESS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19258 N 20TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-5252
Mailing Address - Country:US
Mailing Address - Phone:623-249-2648
Mailing Address - Fax:
Practice Address - Street 1:13825 N 7TH ST
Practice Address - Street 2:SUITE F
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-4342
Practice Address - Country:US
Practice Address - Phone:623-249-2648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-12552101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health