Provider Demographics
NPI:1699242354
Name:BURRIS, KENYATTA CHARLE' (LCSWA)
Entity type:Individual
Prefix:MS
First Name:KENYATTA
Middle Name:CHARLE'
Last Name:BURRIS
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 LEWISTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-1913
Mailing Address - Country:US
Mailing Address - Phone:980-253-2700
Mailing Address - Fax:
Practice Address - Street 1:1207 S COX ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-6911
Practice Address - Country:US
Practice Address - Phone:980-253-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0129981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical