MEDICARE: MARYALICE BURKE

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1679125678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYALICE BURKE

Provider Business Mailing Address
First Line	:	5263 JASMINE CIR N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33714-2142
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	252 JAVA ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11222-5424
Country	:	US
Telephone Number	:	347-952-4750
Fax Number	:

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

Provider Enumeration Date	:	07/10/2019
Last Update Date	:	07/10/2019

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Directions to “ MARYALICE BURKE ” Practice Location

Language	Start Address	Practice Location

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