Provider Demographics
NPI:1558441527
Name:BURKE, MICHAEL M (LICSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:M
Last Name:BURKE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 BRADFORD ST
Mailing Address - Street 2:
Mailing Address - City:PROVINCETOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02657-1745
Mailing Address - Country:US
Mailing Address - Phone:508-717-5070
Mailing Address - Fax:508-487-4468
Practice Address - Street 1:237 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657-2102
Practice Address - Country:US
Practice Address - Phone:508-487-8300
Practice Address - Fax:508-487-8301
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1136821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0000294Medicare PIN