Provider Demographics
NPI:1326635327
Name:BOURKE, KASEY M (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:M
Last Name:BOURKE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6202 CONSTITUTION DR STE D
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1583
Mailing Address - Country:US
Mailing Address - Phone:260-432-0066
Mailing Address - Fax:
Practice Address - Street 1:6202 CONSTITUTION DR STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1583
Practice Address - Country:US
Practice Address - Phone:260-432-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34010557A1041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical