Provider Demographics
NPI:1841875317
Name:BURK, BREANNA (BCBA)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:BURK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W 6TH ST APT 406
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-1279
Mailing Address - Country:US
Mailing Address - Phone:918-636-9763
Mailing Address - Fax:
Practice Address - Street 1:311 BOULEVARD OF THE AMERICAS
Practice Address - Street 2:SUITE 304
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701
Practice Address - Country:US
Practice Address - Phone:918-636-9763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-23-64267103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-23-64267OtherBEHAVIOR ANALYTIC CERTIFICATION BOARD