Provider Demographics
NPI:1710073804
Name:BURKHAM, ROBERT (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BURKHAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W COLLEGE AVE
Mailing Address - Street 2:SUITE 815
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911
Mailing Address - Country:US
Mailing Address - Phone:920-733-1992
Mailing Address - Fax:920-733-1866
Practice Address - Street 1:103 W COLLEGE AVE
Practice Address - Street 2:SUITE 815
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911
Practice Address - Country:US
Practice Address - Phone:920-733-1992
Practice Address - Fax:920-733-1866
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI991057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist