Basic Information
| Provider Information | |||||||||
| NPI: | 1508124561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | CARI | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JESSE | ||||||||
| OtherFirstName: | CARI | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6800 STATE ROUTE 162 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183916405 | ||||||||
| FaxNumber: | 6182884088 | ||||||||
| Practice Location | |||||||||
| Address1: | 6800 STATE ROUTE 162 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183916405 | ||||||||
| FaxNumber: | 6182884088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2012 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146005248 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.