Provider Demographics
NPI:1245319581
Name:BURGERT, CARRIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:BURGERT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 W LOS ANGELES AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-1898
Mailing Address - Country:US
Mailing Address - Phone:805-552-1915
Mailing Address - Fax:
Practice Address - Street 1:144 W LOS ANGELES AVE
Practice Address - Street 2:STE 110
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-1898
Practice Address - Country:US
Practice Address - Phone:805-552-1915
Practice Address - Fax:805-552-1991
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29733174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA264440100OtherDEPT OF LABOR
CAOPT297330OtherBLUE SHIELD INDIVIDUAL
CAZZZ082282OtherBLUE SHIELD
CAWPT29733AMedicare ID - Type UnspecifiedINDIVIDUAL MEDICARE
CAW17334Medicare ID - Type UnspecifiedGROUP MEDICARE