Provider Demographics
NPI:1417019928
Name:BURKE, TRACY DANIEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:DANIEL
Last Name:BURKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-3202
Mailing Address - Country:US
Mailing Address - Phone:610-431-7810
Mailing Address - Fax:610-431-7811
Practice Address - Street 1:104 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19382-3202
Practice Address - Country:US
Practice Address - Phone:610-431-7810
Practice Address - Fax:610-431-7811
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005355L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA603933OtherBC BS PROVIDER