=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306389424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KATIE BURDICK, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2016
-----------------------------------------------------
Last Update Date | 09/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 642 HILLIARD ST STE 1302
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06042-2705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-748-5441
-----------------------------------------------------
Fax | 860-812-2442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 642 HILLIARD ST STE 1302
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06042-2705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-748-5441
-----------------------------------------------------
Fax | 860-812-2442
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KATHERINE BURDICK
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 860-748-5441
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 1537
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------