Provider Demographics
NPI:1922483932
Name:BURKE, BILLY IV
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:
Last Name:BURKE
Suffix:IV
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:PO BOX 477
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-0477
Mailing Address - Country:US
Mailing Address - Phone:707-693-5055
Mailing Address - Fax:
Practice Address - Street 1:1414 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1515
Practice Address - Country:US
Practice Address - Phone:209-468-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC4938101YM0800X
172V00000X
CA4938101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor