Provider Demographics
NPI:1003180068
Name:BURG, WENDY RENEE
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:RENEE
Last Name:BURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 HOLBROOK ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-3809
Mailing Address - Country:US
Mailing Address - Phone:580-716-3411
Mailing Address - Fax:
Practice Address - Street 1:1700 HOLBROOK ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-3809
Practice Address - Country:US
Practice Address - Phone:580-716-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health