Provider Demographics
NPI:1417464728
Name:BURKE, ROXANNE (MED BCBA)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:BURKE
Suffix:
Gender:F
Credentials:MED BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 OCEAN AVE APT C2A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-4700
Mailing Address - Country:US
Mailing Address - Phone:661-863-7770
Mailing Address - Fax:
Practice Address - Street 1:4883 RONSON CT STE I
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1812
Practice Address - Country:US
Practice Address - Phone:760-294-1206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
CA1-20-42766103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician