Provider Demographics
NPI:1447092663
Name:BURKE, CONNOR JAY
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:JAY
Last Name:BURKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 MARTINGALE LN
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-7571
Mailing Address - Country:US
Mailing Address - Phone:310-560-2946
Mailing Address - Fax:
Practice Address - Street 1:862 MARTINGALE LN
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7571
Practice Address - Country:US
Practice Address - Phone:310-560-2946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-24-329528106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician