Provider Demographics
NPI:1851904205
Name:BURGE, KRISTEN M (LMT)
Entity Type:Individual
Prefix:MISS
First Name:KRISTEN
Middle Name:M
Last Name:BURGE
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 1:4885 W PLATO RD
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-9094
Mailing Address - Country:US
Mailing Address - Phone:580-606-0121
Mailing Address - Fax:
Practice Address - Street 1:4564 S HARVARD AVE STE B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2918
Practice Address - Country:US
Practice Address - Phone:918-508-2220
Practice Address - Fax:918-508-2221
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103398225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist