Provider Demographics
NPI:1598045056
Name:BURNSIDE, KATHLEEN M (LMT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:BURNSIDE
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 1:1545 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1459
Mailing Address - Country:US
Mailing Address - Phone:419-494-3563
Mailing Address - Fax:
Practice Address - Street 1:1545 ROSEWOOD DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-1459
Practice Address - Country:US
Practice Address - Phone:419-494-3563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH13300225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist