Provider Demographics
NPI:1114260262
Name:BURKE, SHANIKA LA'TIA (LCSW-C)
Entity Type:Individual
Prefix:
First Name:SHANIKA
Middle Name:LA'TIA
Last Name:BURKE
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 AMHERST LN
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21158-4350
Mailing Address - Country:US
Mailing Address - Phone:443-977-8879
Mailing Address - Fax:
Practice Address - Street 1:10711 RED RUN BLVD STE 112
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5138
Practice Address - Country:US
Practice Address - Phone:443-977-8879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD163181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD443232100Medicaid