Healthcare Provider Details

I. General information

NPI: 1285173831
Provider Name (Legal Business Name): THERESA (TERRY) BURKE MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 WILLAMETTE ST STE 201
EUGENE OR
97405-3170
US

IV. Provider business mailing address

2440 WILLAMETTE ST STE 201
EUGENE OR
97405-3170
US

V. Phone/Fax

Practice location:
  • Phone: 541-321-2278
  • Fax: 541-246-8826
Mailing address:
  • Phone: 541-321-2278
  • Fax: 541-246-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7069
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500724669
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: