Healthcare Provider Details

I. General information

NPI: 1205471661
Provider Name (Legal Business Name): BROOKLYN BURKHART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3706 MEADOWLARK LN
GREAT BEND KS
67530-7465
US

IV. Provider business mailing address

971 E WICHITA AVE
RUSSELL KS
67665-2444
US

V. Phone/Fax

Practice location:
  • Phone: 785-657-7464
  • Fax: 785-445-4042
Mailing address:
  • Phone: 785-657-7464
  • Fax: 785-445-4042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: