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General NPI Number Information
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NPI Number | 1235149642
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Entity Type | Individual
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Provider Name | MEGAN J. BURDICK-GRADE M.A., LMFT
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Gender | Female
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Dates
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Enumeration Date | 08/08/2006
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Last Update Date | 09/17/2008
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Provider Practice Location Address
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Address Line | 1478 KENWOOD CTR SUITE 1
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City | MENASHA
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State | WI
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Zip | 54952-1161
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Country | US
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Telephone | 920-886-9319
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Fax | 920-886-9357
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Provider Business Mailing Address
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Address Line | 3416 S WHIP POOR WILL LN
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City | APPLETON
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State | WI
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Zip | 54915-4563
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Country | US
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Telephone | 920-993-2290
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 595-124
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License Number State | WI
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