MEDICARE: STORMY LYN BURKE PTA, LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA 01617	OH
2	225700000X	Massage Therapist	33.007992	OH

General Provider Information

NPI Number	:	1811223159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STORMY LYN BURKE PTA, LMT

Provider Business Mailing Address
First Line	:	7805 N DIXIE DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-2719
Country	:	US
Telephone Number	:	937-898-3780
Fax Number	:	937-898-3781

Provider Business Practice Location Address
First Line	:	7805 N DIXIE DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-2719
Country	:	US
Telephone Number	:	937-898-3780
Fax Number	:	937-898-3781

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2009
Last Update Date	:	10/21/2009

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