Provider Demographics
NPI:1043812845
Name:BURBECK, LAURA JO
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JO
Last Name:BURBECK
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 1:5456 MIDDLE URBANA RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-9231
Mailing Address - Country:US
Mailing Address - Phone:937-508-7514
Mailing Address - Fax:
Practice Address - Street 1:5456 MIDDLE URBANA RD
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078-9231
Practice Address - Country:US
Practice Address - Phone:937-508-7514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist