Provider Demographics
NPI:1144557158
Name:BURKE, SALLY (LCMHC, MLADC,SEP)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:
Last Name:BURKE
Suffix:
Gender:F
Credentials:LCMHC, MLADC,SEP
Other - Prefix:MS
Other - First Name:SANDY
Other - Middle Name:
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCMHC,MLADC,SEP
Mailing Address - Street 1:20 W PARK ST
Mailing Address - Street 2:SUITE #308
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-0000
Mailing Address - Country:US
Mailing Address - Phone:603-667-8567
Mailing Address - Fax:
Practice Address - Street 1:20 WEST PARK STREET
Practice Address - Street 2:SUITE #308
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-0000
Practice Address - Country:US
Practice Address - Phone:603-667-8567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-11
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0548101YA0400X
NH960101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)