Provider Demographics
NPI:1942465638
Name:BURKETT, STEPHANIE MARIE (MED LPC CACD)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:BURKETT
Suffix:
Gender:F
Credentials:MED LPC CACD
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:WHITMYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED LPC CACD
Mailing Address - Street 1:134 RESERVOIR ROAD
Mailing Address - Street 2:P.O.BOX 225
Mailing Address - City:WEST HICKORY
Mailing Address - State:PA
Mailing Address - Zip Code:16370-0225
Mailing Address - Country:US
Mailing Address - Phone:814-463-9319
Mailing Address - Fax:
Practice Address - Street 1:134 RESERVOIR ROAD
Practice Address - Street 2:
Practice Address - City:WEST HICKORY
Practice Address - State:PA
Practice Address - Zip Code:16370-0225
Practice Address - Country:US
Practice Address - Phone:814-463-9319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA4618101YA0400X
PAPC002631101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024255OtherVALUEOPTIONS
PA1024255960001OtherPROMISE
PA002061860OtherHIGHMARK BCBS