Provider Demographics
NPI:1902230279
Name:BURKE, REBECCA MARIE
Entity Type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:MARIE
Last Name:BURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 W DICKENS AVE
Mailing Address - Street 2:APARTMENT #23
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4189
Mailing Address - Country:US
Mailing Address - Phone:817-366-2570
Mailing Address - Fax:
Practice Address - Street 1:8333 AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-2558
Practice Address - Country:US
Practice Address - Phone:708-398-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-6009293Medicaid