Healthcare Provider Details

I. General information

NPI: 1972591998
Provider Name (Legal Business Name): KEITH YALE BURGER LISW-LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KEITH YALE BURGER LISW-LPCC

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 W MAIN ST
CORTLAND OH
44410-1460
US

IV. Provider business mailing address

197 W MAIN ST
CORTLAND OH
44410-1460
US

V. Phone/Fax

Practice location:
  • Phone: 330-856-6640
  • Fax:
Mailing address:
  • Phone: 330-856-6640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberOH E0000169
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberOH I0000401
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: