MEDICARE: SHANNON MARIE BURKE LPCC

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	T-0130231	NM
2	101YM0800X	Mental Health Counselor	0156191	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1841738820	OTHER		BILLING NPI

General Provider Information

NPI Number	:	1922319938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON MARIE BURKE LPCC

Provider Business Mailing Address
First Line	:	21 DINGO RD
Second Line	:
City	:	MORIARTY
State	:	NM
Zip	:	87035-5498
Country	:	US
Telephone Number	:	505-220-6971
Fax Number	:	505-832-4441

Provider Business Practice Location Address
First Line	:	1209 W US ROUTE 66 STE A
Second Line	:
City	:	MORIARTY
State	:	NM
Zip	:	87035-1039
Country	:	US
Telephone Number	:	505-220-6971
Fax Number	:	505-832-4441

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

Provider Enumeration Date	:	06/24/2010
Last Update Date	:	07/21/2022

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Directions to “ SHANNON MARIE BURKE LPCC” Practice Location

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