Provider Demographics
NPI:1205167525
Name:BURKE, AMIE M (BCBA, MS)
Entity type:Individual
Prefix:
First Name:AMIE
Middle Name:M
Last Name:BURKE
Suffix:
Gender:F
Credentials:BCBA, MS
Other - Prefix:
Other - First Name:AMIE
Other - Middle Name:M
Other - Last Name:MOIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:404 SYMPHONY CV
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-7456
Mailing Address - Country:US
Mailing Address - Phone:815-871-5238
Mailing Address - Fax:815-654-4505
Practice Address - Street 1:580 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2984
Practice Address - Country:US
Practice Address - Phone:608-756-5555
Practice Address - Fax:608-314-2442
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
001-096612103K00000X
WI138-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362769801Medicaid