Provider Demographics
NPI:1255112421
Name:BURGE, TAYLOR S (LPC-IT)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:S
Last Name:BURGE
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 S 76TH ST APT 104
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4690
Mailing Address - Country:US
Mailing Address - Phone:414-334-7061
Mailing Address - Fax:
Practice Address - Street 1:1612 S 76TH ST APT 104
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4690
Practice Address - Country:US
Practice Address - Phone:414-334-7061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5463-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional