Provider Demographics
NPI:1609173533
Name:BURNS, LURETHA KELLY (LCSW)
Entity Type:Individual
Prefix:
First Name:LURETHA
Middle Name:KELLY
Last Name:BURNS
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 1:1241 LEBANON PINEGROVE RD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MS
Mailing Address - Zip Code:39175
Mailing Address - Country:US
Mailing Address - Phone:601-572-4268
Mailing Address - Fax:601-885-6028
Practice Address - Street 1:1241 LEBANON PINEGROVE RD
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MS
Practice Address - Zip Code:39175-9018
Practice Address - Country:US
Practice Address - Phone:601-572-4268
Practice Address - Fax:601-885-6028
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-11
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM6936104100000X
MSC69361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018209Medicaid