Basic Information
| Provider Information | |||||||||
| NPI: | 1043655616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | AISLINN | ||||||||
| MiddleName: | KELLY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLY | ||||||||
| OtherFirstName: | AISLINN | ||||||||
| OtherMiddleName: | ELISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 195 W MAIN ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840432145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013828676 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Practice Location | |||||||||
| Address1: | 195 W MAIN ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840432145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3855194585 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2013 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 60303393902 | UT | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.