Healthcare Provider Details

I. General information

NPI: 1114249257
Provider Name (Legal Business Name): KATHY BURGOA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2010
Last Update Date: 05/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7962 OAKLANDON RD STE 106H
INDIANAPOLIS IN
46236
US

IV. Provider business mailing address

7962 OAKLANDON RD STE 106H
INDIANAPOLIS IN
46236-7502
US

V. Phone/Fax

Practice location:
  • Phone: 317-372-1988
  • Fax:
Mailing address:
  • Phone: 317-372-1988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT20900387
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License NumberMT20900387
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: