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General NPI Number Information
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NPI Number | 1710200548
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Entity Type | Individual
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Provider Name | TINA MICHELLE BURTARD M.S., OTR/L
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Gender | Female
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Dates
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Enumeration Date | 03/08/2010
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Last Update Date | 04/12/2011
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Provider Practice Location Address
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Address Line | 2600 KILEY WAY
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City | PLYMOUTH
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State | WI
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Zip | 53073-5020
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Country | US
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Telephone | 920-459-1409
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Fax |
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Provider Business Mailing Address
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Address Line | 5433 W NATIONAL AVE APT. 211 A
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City | WEST MILWAUKEE
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State | WI
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Zip | 53214-3452
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Country | US
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Telephone | 920-980-1818
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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 | 171W00000X
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Taxonomy Name | Contractor
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License Number | 4488
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State | WI
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