Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 29038 | CA |
Y | 103T00000X | Psychologist | 29038 | CA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 29038 | CA |
N | 103TA0700X | Adult Development & Aging Psychologist | 29038 | CA |
N | 103TB0200X | Cognitive & Behavioral Psychologist | 29038 | CA |
N | 103G00000X | Clinical Psychologist | 29038 | CA |
N | 103TC0700X | Clinical Psychologist | 29038 | CA |
N | 103TC1900X | Counseling Psychologist | 29038 | CA |
N | 103TF0000X | Family Psychologist | 29038 | CA |
N | 103TP2701X | Group Psychotherapist | 29038 | CA |
NPI | 1417395252 |
---|---|
Provider Name | Keith Burke |
First Address | San Diego, CA 92101-4787 |
Second Address | San Diego, CA 92101 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2013 |
Last Update Date | 13/07/2018 |