Provider Demographics
NPI:1477823664
Name:BURDICK, KELLY (LCDC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BURDICK
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4937 DILWORTH CT
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-8836
Mailing Address - Country:US
Mailing Address - Phone:817-730-1482
Mailing Address - Fax:
Practice Address - Street 1:4937 DILWORTH CT
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-8836
Practice Address - Country:US
Practice Address - Phone:817-730-1482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9848101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)