Provider Demographics
NPI:1720732555
Name:BURKE, DIANE YOLANDE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:YOLANDE
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 1:1000 JEFFERSON ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504-1724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4412 PARK RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3130
Practice Address - Country:US
Practice Address - Phone:980-217-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NCA17212101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health