Provider Demographics
NPI:1851969992
Name:BURK, ROGER WESLEY II
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:WESLEY
Last Name:BURK
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 S DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPID
Mailing Address - State:MI
Mailing Address - Zip Code:49507
Mailing Address - Country:US
Mailing Address - Phone:616-247-3815
Mailing Address - Fax:
Practice Address - Street 1:1939 S DIVISION AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPID
Practice Address - State:MI
Practice Address - Zip Code:49507
Practice Address - Country:US
Practice Address - Phone:616-247-3815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker