Provider Demographics
NPI:1942787023
Name:BURNETT, RAYMOND LESLIE IV (ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:LESLIE
Last Name:BURNETT
Suffix:IV
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 N E EXPY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-4003
Mailing Address - Country:US
Mailing Address - Phone:404-480-9330
Mailing Address - Fax:
Practice Address - Street 1:3240 NORTHEAST EXPY NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-4003
Practice Address - Country:US
Practice Address - Phone:404-480-9330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0037812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer