Provider Demographics
NPI:1134743875
Name:BURKE, TANYA LADEAN (LCSWA)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:LADEAN
Last Name:BURKE
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 MARIBEL AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-4529
Mailing Address - Country:US
Mailing Address - Phone:704-999-8079
Mailing Address - Fax:
Practice Address - Street 1:525 S CHURCH ST APT 1609
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-3317
Practice Address - Country:US
Practice Address - Phone:704-963-1164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0142321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical