Provider Demographics
NPI:1518282227
Name:BURGESS, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:POTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:178 PRIVATE ROAD 19423
Mailing Address - Street 2:
Mailing Address - City:SOUTH POINT
Mailing Address - State:OH
Mailing Address - Zip Code:45680-8831
Mailing Address - Country:US
Mailing Address - Phone:740-451-0741
Mailing Address - Fax:740-313-0426
Practice Address - Street 1:178 PRIVATE ROAD 19423
Practice Address - Street 2:
Practice Address - City:SOUTH POINT
Practice Address - State:OH
Practice Address - Zip Code:45680-8831
Practice Address - Country:US
Practice Address - Phone:740-451-0741
Practice Address - Fax:740-313-0426
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid