Provider Demographics
NPI:1093076499
Name:BURMINGHAM, DIEADRA (PT)
Entity Type:Individual
Prefix:
First Name:DIEADRA
Middle Name:
Last Name:BURMINGHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DEA
Other - Middle Name:
Other - Last Name:BURMINGHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:1488 N 600TH RD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66006-7258
Mailing Address - Country:US
Mailing Address - Phone:785-608-4333
Mailing Address - Fax:
Practice Address - Street 1:325 MAINE ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1360
Practice Address - Country:US
Practice Address - Phone:785-505-2712
Practice Address - Fax:785-505-2889
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist