Provider Demographics
NPI:1700960713
Name:BURBACH, DANIEL JOSEPH (PHD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOSEPH
Last Name:BURBACH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 MARITIME DR
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220
Mailing Address - Country:US
Mailing Address - Phone:920-769-0152
Mailing Address - Fax:920-769-0153
Practice Address - Street 1:1020 MARITIME DR
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220
Practice Address - Country:US
Practice Address - Phone:920-769-0152
Practice Address - Fax:920-769-0153
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1529103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
F73460Medicare UPIN