Provider Demographics
NPI:1366703373
Name:BURNHAM, CRYSTAL A
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 W DILLON RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-1297
Mailing Address - Country:US
Mailing Address - Phone:303-554-1600
Mailing Address - Fax:720-328-8188
Practice Address - Street 1:1148 W DILLON RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-1297
Practice Address - Country:US
Practice Address - Phone:303-554-1600
Practice Address - Fax:720-328-8188
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC12108103T00000X
173C00000X
COMT2612225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No173C00000XOther Service ProvidersReflexologist