Provider Demographics
NPI:1780087791
Name:BURKETT, ROBERTA (LEP)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:BURKETT
Suffix:
Gender:F
Credentials:LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9205 BROOKSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-1102
Mailing Address - Country:US
Mailing Address - Phone:619-754-0328
Mailing Address - Fax:619-303-8152
Practice Address - Street 1:2650 CAMINO DEL RIO N STE 211
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1632
Practice Address - Country:US
Practice Address - Phone:619-754-0328
Practice Address - Fax:619-303-8152
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP3395103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling