Provider Demographics
NPI:1679072292
Name:BURKE, GWEN MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:MARIE
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 1:4623 TROUSDALE DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-4584
Mailing Address - Country:US
Mailing Address - Phone:615-301-8431
Mailing Address - Fax:
Practice Address - Street 1:4623 TROUSDALE DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37204
Practice Address - Country:US
Practice Address - Phone:615-301-8431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN54531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5453OtherSTATE LICENSE