Provider Demographics
NPI:1669924189
Name:LEO J BURKE III PSYD PC
Entity type:Organization
Organization Name:LEO J BURKE III PSYD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:III
Authorized Official - Credentials:PSYD
Authorized Official - Phone:215-805-9445
Mailing Address - Street 1:1315 WALNUT ST
Mailing Address - Street 2:SUITE 805
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4719
Mailing Address - Country:US
Mailing Address - Phone:215-805-9445
Mailing Address - Fax:215-545-8496
Practice Address - Street 1:7611 MAPLE ST
Practice Address - Street 2:SUITE B3
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5068
Practice Address - Country:US
Practice Address - Phone:215-805-9445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1375103TC0700X, 103TC2200X
LA304056103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty