=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396909974
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YVONNE SUZETTE BURDETTE LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2008
-----------------------------------------------------
Last Update Date | 07/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5373 E VILLAGE RD STE A
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90808-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-521-5327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15900 GARD AVE APT 23
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-6968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-562-5327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 67913
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------