1508113531 NPI number — KATHERINE V BURDEAUX DPT

Table of content: KATHERINE V BURDEAUX DPT (NPI 1508113531)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508113531 NPI number — KATHERINE V BURDEAUX DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURDEAUX
Provider First Name:
KATHERINE
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508113531
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2222
Provider Business Mailing Address Fax Number:
630-759-9510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1242 STATE AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MARYSVILLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98270-3672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-572-5800
Provider Business Practice Location Address Fax Number:
360-454-9043
Provider Enumeration Date:
08/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT60291583 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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