MEDICARE: MR. ROBERT BURKE RAETZ LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	6401005810	MI

General Provider Information

NPI Number	:	1215290234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT BURKE RAETZ LPC

Provider Business Mailing Address
First Line	:	923 HARBOR CT
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49685-9355
Country	:	US
Telephone Number	:	231-645-8500
Fax Number	:	231-946-6638

Provider Business Practice Location Address
First Line	:	923 HARBOR CT
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49685-9355
Country	:	US
Telephone Number	:	231-645-8500
Fax Number	:	231-946-6638

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2012
Last Update Date	:	07/09/2012

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