Basic Information
| Provider Information | |||||||||
| NPI: | 1114992427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13121 BROOK LANE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217421514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330331 | ||||||||
| FaxNumber: | 3017334038 | ||||||||
| Practice Location | |||||||||
| Address1: | 13215 BROOK LANE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217421514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330331 | ||||||||
| FaxNumber: | 3017334038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 02/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 799 | MD | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 405965400 | 05 | MD | MEDICAID |