Provider Demographics
NPI:1528277951
Name:BURKET, FREYA L (ACSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:FREYA
Middle Name:L
Last Name:BURKET
Suffix:
Gender:F
Credentials:ACSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1994
Mailing Address - Country:US
Mailing Address - Phone:574-647-2624
Mailing Address - Fax:574-239-6460
Practice Address - Street 1:111 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1994
Practice Address - Country:US
Practice Address - Phone:574-647-2624
Practice Address - Fax:574-239-6460
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001653A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34001653AOtherSOCIAL WORK LICENSE
IN138090Medicare ID - Type Unspecified