Provider Demographics
NPI:1295311850
Name:RENEE K BURKE PHD PLLC
Entity type:Organization
Organization Name:RENEE K BURKE PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-618-7443
Mailing Address - Street 1:4527 S 2300 E STE 206
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4501
Mailing Address - Country:US
Mailing Address - Phone:801-618-7443
Mailing Address - Fax:
Practice Address - Street 1:4527 S 2300 E STE 206
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4501
Practice Address - Country:US
Practice Address - Phone:801-618-7443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty