Provider Demographics
NPI:1568623122
Name:BURKETT, SANDRA LOUISE (PHD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LOUISE
Last Name:BURKETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 RICHLAND RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-8212
Mailing Address - Country:US
Mailing Address - Phone:740-389-2910
Mailing Address - Fax:
Practice Address - Street 1:1550 RICHLAND RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-8212
Practice Address - Country:US
Practice Address - Phone:740-389-2910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNONE101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral