Provider Demographics
NPI:1861706608
Name:KIMBERLY T BURDICK,LLC
Entity type:Organization
Organization Name:KIMBERLY T BURDICK,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:TINSLEY
Authorized Official - Last Name:BURDICK
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW,ACSW
Authorized Official - Phone:810-648-3248
Mailing Address - Street 1:1240 W SANILAC RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANDUSKY
Mailing Address - State:MI
Mailing Address - Zip Code:48471-9654
Mailing Address - Country:US
Mailing Address - Phone:810-648-3248
Mailing Address - Fax:810-648-3907
Practice Address - Street 1:1240 W SANILAC RD
Practice Address - Street 2:SUITE D
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-9654
Practice Address - Country:US
Practice Address - Phone:810-648-3248
Practice Address - Fax:810-648-3907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010653331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP47020Medicare PIN