Provider Demographics
NPI:1144689720
Name:BURKE, MOLLIE (PHD HSP)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:BURKE
Suffix:
Gender:F
Credentials:PHD HSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 5TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2939
Mailing Address - Country:US
Mailing Address - Phone:319-358-6520
Mailing Address - Fax:
Practice Address - Street 1:1303 5TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2939
Practice Address - Country:US
Practice Address - Phone:319-358-6520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079938103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program