Provider Demographics
NPI:1598406472
Name:BURNETT, KELVIN JR
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:
Last Name:BURNETT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:984 MULBERRY LN
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4416
Mailing Address - Country:US
Mailing Address - Phone:407-549-8721
Mailing Address - Fax:
Practice Address - Street 1:984 MULBERRY LN
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4416
Practice Address - Country:US
Practice Address - Phone:407-549-8721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBACB772571Medicaid