Provider Demographics
NPI:1851784722
Name:BURKHOLDER, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BURKHOLDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HUNDERTMARK RD STE 205N
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1586
Mailing Address - Country:US
Mailing Address - Phone:952-903-1350
Mailing Address - Fax:952-426-3856
Practice Address - Street 1:111 HUNDERTMARK RD STE 205N
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1586
Practice Address - Country:US
Practice Address - Phone:952-426-3856
Practice Address - Fax:952-426-3856
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-16
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.010249101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor