Provider Demographics
NPI:1609154012
Name:BURKE, SANDRA L (PHD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:L
Last Name:BURKE
Suffix:
Gender:F
Credentials:PHD
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 182
Mailing Address - Street 2:
Mailing Address - City:CHURCH CREEK
Mailing Address - State:MD
Mailing Address - Zip Code:21622
Mailing Address - Country:US
Mailing Address - Phone:310-866-8126
Mailing Address - Fax:
Practice Address - Street 1:1947 DIVISADERO ST
Practice Address - Street 2:SUITE 1-A
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2532
Practice Address - Country:US
Practice Address - Phone:310-866-8126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2021-06-08
Deactivation Date:2018-08-09
Deactivation Code:
Reactivation Date:2021-06-08
Provider Licenses
StateLicense IDTaxonomies
CA24348103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24348OtherLICENSE NUMBER