Provider Demographics
NPI:1770245045
Name:BURKE, PATRICIA TABOR (MED, PLPC, NCC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:TABOR
Last Name:BURKE
Suffix:
Gender:F
Credentials:MED, PLPC, NCC
Other - Prefix:
Other - First Name:TABOR
Other - Middle Name:
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, PLPC, NCC
Mailing Address - Street 1:7148 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-4416
Mailing Address - Country:US
Mailing Address - Phone:314-604-2210
Mailing Address - Fax:
Practice Address - Street 1:7711 BONHOMME AVE STE 850
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-1964
Practice Address - Country:US
Practice Address - Phone:314-384-6547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021040961101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health