Provider Demographics
NPI:1144788852
Name:BURKE, DUSTIN CARL
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:CARL
Last Name:BURKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DUSTIN
Other - Middle Name:CARL
Other - Last Name:COYNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6130 W TROPICANA AVE STE 145
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4604
Mailing Address - Country:US
Mailing Address - Phone:702-900-7698
Mailing Address - Fax:702-825-0791
Practice Address - Street 1:2820 W CHARLESTON BLVD STE 22
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1933
Practice Address - Country:US
Practice Address - Phone:702-900-7698
Practice Address - Fax:702-825-0791
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-19-87709106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician