Provider Demographics
NPI:1316198260
Name:BURKE, KATHLEEN SUE
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:SUE
Last Name:BURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 WASHINGTON
Mailing Address - Street 2:P.O. BOX 575
Mailing Address - City:MONTROSE
Mailing Address - State:MI
Mailing Address - Zip Code:48457-7719
Mailing Address - Country:US
Mailing Address - Phone:810-639-4520
Mailing Address - Fax:
Practice Address - Street 1:138 WASHINGTON
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:MI
Practice Address - Zip Code:48457-7719
Practice Address - Country:US
Practice Address - Phone:810-639-4520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF 250247793320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9182961Medicaid