Provider Demographics
NPI:1417143751
Name:BURKE, BRENDA LEE (MSW, CPM)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:LEE
Last Name:BURKE
Suffix:
Gender:F
Credentials:MSW, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-1626
Mailing Address - Country:US
Mailing Address - Phone:563-382-0178
Mailing Address - Fax:
Practice Address - Street 1:720 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-1626
Practice Address - Country:US
Practice Address - Phone:563-382-0178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100-049176B00000X
IA0068381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical