Provider Demographics
NPI:1952534026
Name:BURQUE, BRANDI ELIZABETH (PHD)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:ELIZABETH
Last Name:BURQUE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 ROCKDALE DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-2051
Mailing Address - Country:US
Mailing Address - Phone:954-802-7419
Mailing Address - Fax:
Practice Address - Street 1:3915 ROCKDALE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-2051
Practice Address - Country:US
Practice Address - Phone:954-802-7419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1614103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical