Basic Information
| Provider Information | |||||||||
| NPI: | 1720079932 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKETT | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | POLK | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102222 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
| FaxNumber: | 2392783350 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 5TH AVE N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278210017 | ||||||||
| FaxNumber: | 7278227473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY4694 | FL | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 254016941 | 05 | FL | MEDICAID |