Provider Demographics
NPI:1275281040
Name:BURGESS, KRISTIE SUMMER
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:SUMMER
Last Name:BURGESS
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 1:5269 LOVING RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30560-2509
Mailing Address - Country:US
Mailing Address - Phone:706-258-7804
Mailing Address - Fax:
Practice Address - Street 1:2800 SCENIC DR STE 12
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-1402
Practice Address - Country:US
Practice Address - Phone:706-946-0466
Practice Address - Fax:888-974-1438
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-196027106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician