Provider Demographics
NPI:1811762545
Name:BURDELL, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BURDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-0024
Mailing Address - Country:US
Mailing Address - Phone:574-222-8028
Mailing Address - Fax:
Practice Address - Street 1:3220 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-3028
Practice Address - Country:US
Practice Address - Phone:574-222-2466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88002175A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health