Provider Demographics
NPI:1407904543
Name:BURKE, KATHLEEN R (PHD, RN, CS)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:R
Last Name:BURKE
Suffix:
Gender:F
Credentials:PHD, RN, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MILITIA DR
Mailing Address - Street 2:SUITE 17
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-4737
Mailing Address - Country:US
Mailing Address - Phone:781-861-9797
Mailing Address - Fax:781-861-9797
Practice Address - Street 1:4 MILITIA DR
Practice Address - Street 2:SUITE 17
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-4737
Practice Address - Country:US
Practice Address - Phone:781-861-9797
Practice Address - Fax:781-861-9797
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6858103TC2200X, 103TC0700X
MA116459163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA212553000OtherMBC
MAW05424OtherBC & BS
MAW05424OtherBC & BS