Provider Demographics
NPI:1609451871
Name:BURBANK, KIMBERLY ANGELA (LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANGELA
Last Name:BURBANK
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 1:224 OAKBROOKE DR UNIT 8
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1836
Mailing Address - Country:US
Mailing Address - Phone:743-776-7683
Mailing Address - Fax:
Practice Address - Street 1:56711 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:NEW HUDSON
Practice Address - State:MI
Practice Address - Zip Code:48165-8524
Practice Address - Country:US
Practice Address - Phone:248-667-9904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501008662225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist