Provider Demographics
NPI:1467116962
Name:BURDICK, MICHELLE R
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:BURDICK
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 1:7995 TURNBERRY DR
Mailing Address - Street 2:
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-9496
Mailing Address - Country:US
Mailing Address - Phone:734-550-9558
Mailing Address - Fax:
Practice Address - Street 1:28900 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-9241
Practice Address - Country:US
Practice Address - Phone:734-436-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013237.103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling