Provider Demographics
NPI:1265576110
Name:BURDICK, GLENN (MA, LMSW)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:BURDICK
Suffix:
Gender:M
Credentials:MA, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 S HURON PKWY
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-5124
Mailing Address - Country:US
Mailing Address - Phone:734-395-2122
Mailing Address - Fax:815-377-3564
Practice Address - Street 1:2345 S HURON PKWY
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5124
Practice Address - Country:US
Practice Address - Phone:734-395-2122
Practice Address - Fax:815-377-3564
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010660901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008971320OtherBCBS PIN NUMBER