Provider Demographics
NPI:1740729888
Name:BURGHARD, KRISTIN
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:BURGHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:BURTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSW
Mailing Address - Street 1:65 MESSIMER DR. #2
Mailing Address - Street 2:
Mailing Address - City:NEWARD
Mailing Address - State:OH
Mailing Address - Zip Code:43055
Mailing Address - Country:US
Mailing Address - Phone:419-545-5130
Mailing Address - Fax:
Practice Address - Street 1:65 MESSIMER DR UNIT 2
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1899
Practice Address - Country:US
Practice Address - Phone:419-545-5130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS. 1451334104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker