Provider Demographics
NPI:1568122067
Name:BURKE, LAQUASHA (LCSW)
Entity Type:Individual
Prefix:
First Name:LAQUASHA
Middle Name:
Last Name:BURKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3235 DISCOVERY LN
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-5408
Mailing Address - Country:US
Mailing Address - Phone:832-403-7577
Mailing Address - Fax:859-201-1151
Practice Address - Street 1:3235 DISCOVERY LN
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-5408
Practice Address - Country:US
Practice Address - Phone:832-403-7577
Practice Address - Fax:859-201-1151
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX603081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX394812701Medicaid