Provider Demographics
NPI:1750811998
Name:BURK, GWENDOLYN LOUISE
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:LOUISE
Last Name:BURK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2027 16TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-3921
Mailing Address - Country:US
Mailing Address - Phone:813-312-3036
Mailing Address - Fax:813-438-8973
Practice Address - Street 1:10300 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-3813
Practice Address - Country:US
Practice Address - Phone:561-790-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW63331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW6333OtherSOCIAL WORK