Provider Demographics
NPI:1841552353
Name:BURKHOLDER, KASSIE
Entity type:Individual
Prefix:
First Name:KASSIE
Middle Name:
Last Name:BURKHOLDER
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 1:34350 RIDGE RD # D12
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3088
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22001 FAIRMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-4819
Practice Address - Country:US
Practice Address - Phone:216-932-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND. 2012187235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist