Provider Demographics
NPI:1275120040
Name:LEVALLEY, BURKE J
Entity Type:Individual
Prefix:
First Name:BURKE
Middle Name:J
Last Name:LEVALLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 RUSH CREEK PKWY # 301
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-9608
Mailing Address - Country:US
Mailing Address - Phone:816-691-5103
Mailing Address - Fax:
Practice Address - Street 1:550 RUSH CREEK PKWY # 301
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-9608
Practice Address - Country:US
Practice Address - Phone:816-691-5103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
KS2972103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling