Provider Demographics
NPI:1649647520
Name:BURT, ANDREA (PT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BURT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 TRI PARK WAY STE A
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-1698
Mailing Address - Country:US
Mailing Address - Phone:920-830-6697
Mailing Address - Fax:920-830-6707
Practice Address - Street 1:1650 TRI PARK WAY STE A
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1698
Practice Address - Country:US
Practice Address - Phone:920-830-6697
Practice Address - Fax:920-830-6707
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist