Provider Demographics
NPI:1306445192
Name:BURKE, ATHENA EVAMARIE (LSW)
Entity type:Individual
Prefix:
First Name:ATHENA
Middle Name:EVAMARIE
Last Name:BURKE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2036
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-8036
Mailing Address - Country:US
Mailing Address - Phone:732-458-1700
Mailing Address - Fax:
Practice Address - Street 1:591 LAKEHURST RD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-8045
Practice Address - Country:US
Practice Address - Phone:732-458-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06603400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid