Healthcare Provider Details

I. General information

NPI: 1457710170
Provider Name (Legal Business Name): HEATHER ANN BURK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER DORGAN

II. Dates (important events)

Enumeration Date: 02/23/2016
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 ANN ARBOR RD
JACKSON MI
49201-8801
US

IV. Provider business mailing address

11241 SAND HILL DR
GRASS LAKE MI
49240-9688
US

V. Phone/Fax

Practice location:
  • Phone: 517-879-1505
  • Fax:
Mailing address:
  • Phone: 517-250-0133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT28710
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501010546
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: