Provider Demographics
NPI:1649364100
Name:BURKE, BRODERICK EUGENE (LADAC)
Entity type:Individual
Prefix:MR
First Name:BRODERICK
Middle Name:EUGENE
Last Name:BURKE
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 LEBANON ROAD
Mailing Address - Street 2:
Mailing Address - City:MURFEESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129
Mailing Address - Country:US
Mailing Address - Phone:615-867-6000
Mailing Address - Fax:
Practice Address - Street 1:3400 LEBANON ROAD
Practice Address - Street 2:
Practice Address - City:MURFEESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129
Practice Address - Country:US
Practice Address - Phone:615-867-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDC0000000860101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)