Provider Demographics
NPI:1558620849
Name:BURKE, HEATHER M
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:M
Last Name:BURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40422 RIVERWOOD ESTATES LN
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NY
Mailing Address - Zip Code:13624-4118
Mailing Address - Country:US
Mailing Address - Phone:415-577-7804
Mailing Address - Fax:
Practice Address - Street 1:11050 MT BELVEDERE BLVD
Practice Address - Street 2:USA MBDACC
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:415-577-7804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21850103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical