Healthcare Provider Details

I. General information

NPI: 1053720250
Provider Name (Legal Business Name): KEVIN BURKE PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD NAVAL HOSPITAL
CAM LEJEUNE NC
28547-2538
US

IV. Provider business mailing address

100 BREWSTER BLVD NAVAL HOSPITAL
CAMP LEJEUNE NC
28547-2538
US

V. Phone/Fax

Practice location:
  • Phone: 910-451-1053
  • Fax:
Mailing address:
  • Phone: 910-451-1053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4684
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: