Provider Demographics
NPI:1528456282
Name:BURKHARDT-SIDEBOTTOM, AMBER DAWN (LMSW)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:DAWN
Last Name:BURKHARDT-SIDEBOTTOM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8139 ERNST RD.
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48158-9565
Mailing Address - Country:US
Mailing Address - Phone:734-276-2765
Mailing Address - Fax:
Practice Address - Street 1:8139 ERNST RD.
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48158-9565
Practice Address - Country:US
Practice Address - Phone:734-276-2765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010879771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical