Provider Demographics
NPI:1578033684
Name:BURKES, CORVETTE
Entity Type:Individual
Prefix:
First Name:CORVETTE
Middle Name:
Last Name:BURKES
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 1:5898 CADILLAC AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3128
Mailing Address - Country:US
Mailing Address - Phone:847-306-9843
Mailing Address - Fax:
Practice Address - Street 1:5898 CADILLAC AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3128
Practice Address - Country:US
Practice Address - Phone:847-306-9843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-01
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician