Provider Demographics
NPI:1053758300
Name:BURRIS, CARRIE A (LICSW)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
Last Name:BURRIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 14TH ST W STE 290
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-4078
Mailing Address - Country:US
Mailing Address - Phone:701-334-6442
Mailing Address - Fax:
Practice Address - Street 1:24 W RAILROAD AVE SUITE 16
Practice Address - Street 2:
Practice Address - City:RAY
Practice Address - State:ND
Practice Address - Zip Code:58849
Practice Address - Country:US
Practice Address - Phone:701-568-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-357741041C0700X
ND56191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND5619OtherND BOARD OF SW EXAMINERS
IDLCSW-35774OtherID BUREAU OF OCCUPATIONAL LICENSES