Provider Demographics
NPI:1821095399
Name:BURKE, ELLINOR R (PHD)
Entity Type:Individual
Prefix:
First Name:ELLINOR
Middle Name:R
Last Name:BURKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5099
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-5099
Mailing Address - Country:US
Mailing Address - Phone:912-882-3662
Mailing Address - Fax:912-882-7720
Practice Address - Street 1:1201 SHADOWLAWN DR STE 101
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-4074
Practice Address - Country:US
Practice Address - Phone:912-744-0993
Practice Address - Fax:912-744-0993
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPSY003747103T00000X
NJ35SI00313400103T00000X
GAPSY003747103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6248306Medicaid
NJR0792583Medicare ID - Type Unspecified
NJ6248306Medicaid