Provider Demographics
NPI:1629620836
Name:BURTON, KRISTAL (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:
Last Name:BURTON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 FOURTH AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:MS
Mailing Address - Zip Code:39327-9713
Mailing Address - Country:US
Mailing Address - Phone:601-934-1497
Mailing Address - Fax:
Practice Address - Street 1:357 TOWNE CENTER PL STE 402
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4844
Practice Address - Country:US
Practice Address - Phone:601-934-1497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0529101YP2500X
MS2703101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty