Provider Demographics
NPI:1013511625
Name:BURCHARD, CLYDE (OTR/L)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:BURCHARD
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SAC CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50583-2604
Mailing Address - Country:US
Mailing Address - Phone:870-656-3488
Mailing Address - Fax:
Practice Address - Street 1:1409 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:IA
Practice Address - Zip Code:51449-1578
Practice Address - Country:US
Practice Address - Phone:712-464-7951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01651225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist