Provider Demographics
NPI:1679030894
Name:BURDA, REBECCA J (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:BURDA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3251 GRAYDON AVE
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-1175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1541 ANNEX RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-9803
Practice Address - Country:US
Practice Address - Phone:920-674-8796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-24
Last Update Date:2019-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8958-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical