Provider Demographics
NPI:1477194249
Name:BURKHART, MALORIE JEAN (LMT)
Entity Type:Individual
Prefix:
First Name:MALORIE
Middle Name:JEAN
Last Name:BURKHART
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-9368
Mailing Address - Country:US
Mailing Address - Phone:920-664-3448
Mailing Address - Fax:
Practice Address - Street 1:29 W DAVENPORT ST
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-3456
Practice Address - Country:US
Practice Address - Phone:715-420-2005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4967-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist