Provider Demographics
NPI:1265104012
Name:BURKE, NAOMI ALIXANDRA NICHELLE (LCSW, LCADC)
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:ALIXANDRA NICHELLE
Last Name:BURKE
Suffix:
Gender:F
Credentials:LCSW, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 LORRAINE CT
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1318
Mailing Address - Country:US
Mailing Address - Phone:859-267-7141
Mailing Address - Fax:
Practice Address - Street 1:210 N BROADWAY ST STE 1
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-2212
Practice Address - Country:US
Practice Address - Phone:859-267-7141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2549091041C0700X
KY279096101YA0400X
KY2572961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100782040Medicaid