=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972780880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BURKE BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2008
-----------------------------------------------------
Last Update Date | 04/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 FISHBACK RD
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62901-6307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-527-6144
-----------------------------------------------------
Fax | 618-529-1693
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1442
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62903-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-527-6144
-----------------------------------------------------
Fax | 618-529-1693
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DR. PHILIP A BURKE
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 618-527-6144
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071007221
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------