Provider Demographics
NPI:1801161641
Name:BURKE, CAROLINE A (PHD, LP)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:A
Last Name:BURKE
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 SARGENT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1532
Mailing Address - Country:US
Mailing Address - Phone:651-808-0324
Mailing Address - Fax:
Practice Address - Street 1:516 MISSION HOUSE LN
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-2571
Practice Address - Country:US
Practice Address - Phone:651-636-5124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 5471174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist