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General NPI Number Information
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NPI Number | 1578034245
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Entity Type | Individual
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Provider Name | BRENNA BOURKE LCSW
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Gender | Female
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Dates
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Enumeration Date | 12/06/2018
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Last Update Date | 04/10/2019
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Provider Practice Location Address
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Address Line | 1718 SHERMAN AVE STE 210
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City | EVANSTON
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State | IL
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Zip | 60201-5610
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Country | US
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Telephone | 847-577-1501
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Fax | 847-577-3858
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Provider Business Mailing Address
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Address Line | 1112 N HOYNE AVE
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City | CHICAGO
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State | IL
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Zip | 60622-3620
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Country | US
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Telephone | 708-721-1288
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.017804
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License Number State | IL
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