Provider Demographics
NPI:1477881894
Name:BURSON, KELLIE SUZANNE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:KELLIE
Middle Name:SUZANNE
Last Name:BURSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 CARSON ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-6852
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 CARSON ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-6852
Practice Address - Country:US
Practice Address - Phone:870-356-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A590174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist