Provider Demographics
NPI:1912510033
Name:BURKE, DEMETRIUS
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:BURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEMETRIUS
Other - Middle Name:ALEXANDRA
Other - Last Name:BURKE-HAGERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DEMETRIUS BURKE
Mailing Address - Street 1:1047 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1551
Mailing Address - Country:US
Mailing Address - Phone:517-285-0890
Mailing Address - Fax:
Practice Address - Street 1:1111 40TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-6084
Practice Address - Country:US
Practice Address - Phone:616-318-5873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1912510033Medicaid