Provider Demographics
NPI:1437204138
Name:BURKE, LISA ANN (MSW LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:BURKE
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 1:2678 VONDA DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311
Mailing Address - Country:US
Mailing Address - Phone:920-469-2753
Mailing Address - Fax:
Practice Address - Street 1:2339 CEDAR RIDGE COURT
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303
Practice Address - Country:US
Practice Address - Phone:920-497-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69651231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40944100Medicaid