Provider Demographics
NPI:1316783418
Name:BURGER, STEPHANIE D (EDS)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:D
Last Name:BURGER
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:D
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 BIG RED DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1873
Mailing Address - Country:US
Mailing Address - Phone:574-344-8174
Mailing Address - Fax:
Practice Address - Street 1:1 BIG RED DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1873
Practice Address - Country:US
Practice Address - Phone:574-344-8174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10044312103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool