MEDICARE: SOPHIA CATHERINE BURKE LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	178.010817	IL
2	101YP2500X	Professional Counselor	180.011057	IL

General Provider Information

NPI Number	:	1447630769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIA CATHERINE BURKE LCPC

Provider Business Mailing Address
First Line	:	4081 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2117
Country	:	US
Telephone Number	:	773-883-9100
Fax Number	:	773-883-0005

Provider Business Practice Location Address
First Line	:	4081 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2117
Country	:	US
Telephone Number	:	773-883-9100
Fax Number	:	773-883-0005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2015
Last Update Date	:	08/18/2017

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