Provider Demographics
NPI:1720368939
Name:BURKE, ROSE MARIE
Entity Type:Individual
Prefix:
First Name:ROSE MARIE
Middle Name:
Last Name:BURKE
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 1:22 PINE STREET
Mailing Address - Street 2:SUITE 103A
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010
Mailing Address - Country:US
Mailing Address - Phone:860-261-7115
Mailing Address - Fax:
Practice Address - Street 1:22 PINE STREET
Practice Address - Street 2:SUITE 103A
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010
Practice Address - Country:US
Practice Address - Phone:860-261-7115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0095601041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker