Healthcare Provider Details

I. General information

NPI: 1821362831
Provider Name (Legal Business Name): KATHERINE E BURKE SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 03/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 AIRPORT RD SUITE 103
VIROQUA WI
54665-1159
US

IV. Provider business mailing address

210 AIRPORT RD SUITE 103
VIROQUA WI
54665-1159
US

V. Phone/Fax

Practice location:
  • Phone: 608-638-7420
  • Fax: 608-638-7429
Mailing address:
  • Phone: 608-638-7420
  • Fax: 608-638-7429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16412-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: