Provider Demographics
NPI:1992813117
Name:BURKHARDT, MYRA MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:MARIE
Last Name:BURKHARDT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23477 COUNTY HIGHWAY Y
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54653-8707
Mailing Address - Country:US
Mailing Address - Phone:608-486-4090
Mailing Address - Fax:608-486-4110
Practice Address - Street 1:1540 HERITAGE BLVD
Practice Address - Street 2:SUITE 101A
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-1417
Practice Address - Country:US
Practice Address - Phone:608-786-4989
Practice Address - Fax:608-786-2321
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3650-024225100000X
MN5722225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3650-024OtherWI STATE PT LICENSE #
MN5722OtherMN STATE LICENSE #
WI3650-024OtherWI STATE PT LICENSE #
WIPO9977Medicare UPIN