Basic Information
Provider Information | |||||||||
NPI: | 1548317399 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BURNETT | ||||||||
FirstName: | DARLA | ||||||||
MiddleName: | MICHELE RUTHERFORD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D., M.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 98509 | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708849509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2257692200 | ||||||||
FaxNumber: | 2257682185 | ||||||||
Practice Location | |||||||||
Address1: | 10101 PARK ROWE AVE | ||||||||
Address2: | STE. 200 | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708101686 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2257692200 | ||||||||
FaxNumber: | 2257682185 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2007 | ||||||||
LastUpdateDate: | 03/02/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 871MP | LA | Y |   | Behavioral Health & Social Service Providers | Psychologist |   | 103TP0016X | 871MP | LA | N |   | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
ID Information
ID | Type | State | Issuer | Description | MP.000871 | 01 | LA | MP LICENSE | OTHER |