Healthcare Provider Details

I. General information

NPI: 1841638582
Provider Name (Legal Business Name): BENJAMIN J BURKE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 06/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10799 N 90TH ST STE 100
SCOTTSDALE AZ
85260-6110
US

IV. Provider business mailing address

1400 E SOUTHERN AVE STE. 735
TEMPE AZ
85282-5691
US

V. Phone/Fax

Practice location:
  • Phone: 480-804-0326
  • Fax: 480-804-0083
Mailing address:
  • Phone: 480-804-0326
  • Fax: 480-804-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-14063
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLASAC-13288
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-15546
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: