Provider Demographics
NPI:1336774090
Name:BURKE, MARLEY ALEXANDRA
Entity Type:Individual
Prefix:MISS
First Name:MARLEY
Middle Name:ALEXANDRA
Last Name:BURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2332 CANTERCLUB TRL
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-4025
Mailing Address - Country:US
Mailing Address - Phone:321-440-7162
Mailing Address - Fax:
Practice Address - Street 1:791 RINEHART RD
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4876
Practice Address - Country:US
Practice Address - Phone:866-610-0580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB620541008090OtherDRIVER'S LICENSE