Provider Demographics
NPI:1952493470
Name:BURGOYNE, RENE ANN (MS, ATRL-BC)
Entity Type:Individual
Prefix:MRS
First Name:RENE
Middle Name:ANN
Last Name:BURGOYNE
Suffix:
Gender:F
Credentials:MS, ATRL-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12970 W BLUEMOUND RD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2607
Mailing Address - Country:US
Mailing Address - Phone:262-780-1020
Mailing Address - Fax:262-780-1022
Practice Address - Street 1:12970 W BLUEMOUND RD
Practice Address - Street 2:SUITE 308
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2607
Practice Address - Country:US
Practice Address - Phone:262-780-1020
Practice Address - Fax:262-780-1022
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66-036221700000X
WI3853-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI66-036OtherART THERAPIST
WI40967900Medicaid