Provider Demographics
NPI:1548419641
Name:BURNSIDE, KENDRA (LCSW)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:BURNSIDE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 TACKETT'S MILL DRIVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192
Mailing Address - Country:US
Mailing Address - Phone:703-494-1534
Mailing Address - Fax:
Practice Address - Street 1:2241 TACKETT'S MILL DRIVE
Practice Address - Street 2:SUITE G
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:703-494-1434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK35441041C0700X
VA09040102221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical