Provider Demographics
NPI:1063118875
Name:BURNS, KELLI (LMSW)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 WESSEX DR
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3493
Mailing Address - Country:US
Mailing Address - Phone:707-580-4078
Mailing Address - Fax:
Practice Address - Street 1:108 WESSEX DR
Practice Address - Street 2:
Practice Address - City:BONAIRE
Practice Address - State:GA
Practice Address - Zip Code:31005-3493
Practice Address - Country:US
Practice Address - Phone:707-580-4078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW010981104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker