Provider Demographics
NPI:1053805325
Name:BURT, NICOLE (PHD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BURT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 N 16TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4446
Mailing Address - Country:US
Mailing Address - Phone:602-615-0381
Mailing Address - Fax:
Practice Address - Street 1:7600 N 16TH ST STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4446
Practice Address - Country:US
Practice Address - Phone:602-615-0381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TM1800X
AZ4975103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities