Provider Demographics
NPI:1710200548
Name:BURTARD, TINA MICHELLE (MS, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:MICHELLE
Last Name:BURTARD
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5433 W NATIONAL AVE
Mailing Address - Street 2:APT. 211 A
Mailing Address - City:WEST MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3452
Mailing Address - Country:US
Mailing Address - Phone:920-980-1818
Mailing Address - Fax:
Practice Address - Street 1:2600 KILEY WAY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-5020
Practice Address - Country:US
Practice Address - Phone:920-459-1409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4488171W00000X
WI225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171W00000XOther Service ProvidersContractor