Provider Demographics
NPI:1235149642
Name:BURDICK-GRADE, MEGAN J (MA, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:J
Last Name:BURDICK-GRADE
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3416 S WHIP POOR WILL LN
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-4563
Mailing Address - Country:US
Mailing Address - Phone:920-993-2290
Mailing Address - Fax:
Practice Address - Street 1:1478 KENWOOD CTR
Practice Address - Street 2:SUITE 1
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1161
Practice Address - Country:US
Practice Address - Phone:920-886-9319
Practice Address - Fax:920-886-9357
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI595-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39798700Medicaid