Provider Demographics
NPI:1821362831
Name:BURKE, KATHERINE E (SAC-IT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:E
Last Name:BURKE
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 AIRPORT RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-1159
Mailing Address - Country:US
Mailing Address - Phone:608-638-7420
Mailing Address - Fax:608-638-7429
Practice Address - Street 1:210 AIRPORT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1159
Practice Address - Country:US
Practice Address - Phone:608-638-7420
Practice Address - Fax:608-638-7429
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16412-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI16412-130OtherSAC-IT