Basic Information
| Provider Information | |||||||||
| NPI: | 1386981934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | NOELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1129 MACKLIND AVENUE | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142899408 | ||||||||
| FaxNumber: | 3142899414 | ||||||||
| Practice Location | |||||||||
| Address1: | 1129 MACKLIND AVENUE | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362966206 | ||||||||
| FaxNumber: | 6362960102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2013 | ||||||||
| LastUpdateDate: | 09/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.