Provider Demographics
NPI:1316196405
Name:KENDRA BURNSIDE LCSW INC PC
Entity Type:Organization
Organization Name:KENDRA BURNSIDE LCSW INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNSIDE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:580-436-7120
Mailing Address - Street 1:2100 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-1048
Mailing Address - Country:US
Mailing Address - Phone:580-436-7120
Mailing Address - Fax:580-436-7121
Practice Address - Street 1:2100 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-1048
Practice Address - Country:US
Practice Address - Phone:580-436-7120
Practice Address - Fax:580-436-7121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLCSW251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health