Provider Demographics
NPI:1326522103
Name:BURCH, KELSEA RAE
Entity Type:Individual
Prefix:
First Name:KELSEA
Middle Name:RAE
Last Name:BURCH
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 1:5302 HIDALGO ST
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-6733
Mailing Address - Country:US
Mailing Address - Phone:805-279-7105
Mailing Address - Fax:
Practice Address - Street 1:501 W BROADWAY STE 800
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3546
Practice Address - Country:US
Practice Address - Phone:805-279-7105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician