Provider Demographics
NPI:1659963833
Name:BURK, ROBERTA JANE (AUD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:JANE
Last Name:BURK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:DESPLINTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:2945 TRINITY GARDEN DR APT 122
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76118-4713
Mailing Address - Country:US
Mailing Address - Phone:281-239-1895
Mailing Address - Fax:
Practice Address - Street 1:647 S GREAT SOUTHWEST PKWY STE 103
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1007
Practice Address - Country:US
Practice Address - Phone:817-595-3700
Practice Address - Fax:817-595-3701
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81316231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81316OtherTEXAS AUDIOLOGIST LICENSE