Provider Demographics
NPI:1972591998
Name:BURGER, KEITH YALE (LISW-LPCC)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:YALE
Last Name:BURGER
Suffix:
Gender:M
Credentials:LISW-LPCC
Other - Prefix:MR
Other - First Name:KEITH
Other - Middle Name:YALE
Other - Last Name:BURGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW-LPCC
Mailing Address - Street 1:197 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-1460
Mailing Address - Country:US
Mailing Address - Phone:330-856-6640
Mailing Address - Fax:
Practice Address - Street 1:197 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-1460
Practice Address - Country:US
Practice Address - Phone:330-856-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH E0000169101YP2500X
OHOH I00004011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBUSW16021Medicare ID - Type Unspecified