MEDICARE: VANESSA CHRISTINE 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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1679135727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANESSA CHRISTINE BURKE

Provider Business Mailing Address
First Line	:	1330 NIATROSS ST
Second Line	:
City	:	ASTOR
State	:	FL
Zip	:	32102-7978
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4647 CLYDE MORRIS BLVD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-3000
Country	:	US
Telephone Number	:	386-767-3752
Fax Number	:

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

Provider Enumeration Date	:	06/28/2019
Last Update Date	:	06/28/2019

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Directions to “ VANESSA CHRISTINE BURKE ” Practice Location

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