Healthcare Provider Details

I. General information

NPI: 1407904543
Provider Name (Legal Business Name): KATHLEEN R. BURKE PHD, RN, CS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MILITIA DR SUITE 17
LEXINGTON MA
02421-4737
US

IV. Provider business mailing address

4 MILITIA DR SUITE 17
LEXINGTON MA
02421-4737
US

V. Phone/Fax

Practice location:
  • Phone: 781-861-9797
  • Fax: 781-861-9797
Mailing address:
  • Phone: 781-861-9797
  • Fax: 781-861-9797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6858
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6858
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number116459
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: