Provider Demographics
NPI:1376170589
Name:BURG, CARRIE DOROTHY (MS, LAT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:DOROTHY
Last Name:BURG
Suffix:
Gender:F
Credentials:MS, LAT
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:DOROTHY
Other - Last Name:KLEMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, ATC
Mailing Address - Street 1:1550 HOBBS DR
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-2027
Mailing Address - Country:US
Mailing Address - Phone:262-740-4370
Mailing Address - Fax:262-740-4379
Practice Address - Street 1:1550 HOBBS DR
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-2027
Practice Address - Country:US
Practice Address - Phone:262-740-4370
Practice Address - Fax:262-740-4379
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1641-392081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine