Healthcare Provider Details

I. General information

NPI: 1871337519
Provider Name (Legal Business Name): AVERY ELISABETH BURKE CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 INDUSTRIAL DR
OWENSBORO KY
42301-8715
US

IV. Provider business mailing address

5653 JACK HINTON RD
PHILPOT KY
42366-8815
US

V. Phone/Fax

Practice location:
  • Phone: 270-689-6800
  • Fax:
Mailing address:
  • Phone: 270-231-9647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number258524
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: