Healthcare Provider Details

I. General information

NPI: 1760682991
Provider Name (Legal Business Name): LAURA LOUISE BURKETT M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date: 11/05/2015
Reactivation Date: 05/24/2023

III. Provider practice location address

3200 RED LION RD APT 17D
PHILADELPHIA PA
19114-1129
US

IV. Provider business mailing address

3200 RED LION RD APT 17D
PHILADELPHIA PA
19114-1129
US

V. Phone/Fax

Practice location:
  • Phone: 215-637-0451
  • Fax:
Mailing address:
  • Phone: 215-637-0451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: