Provider Demographics
NPI:1639405798
Name:BURNETT, KELLY A (ACSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:BURNETT
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 EUCLID AVE
Mailing Address - Street 2:#108
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3188 AIRWAY AVE
Practice Address - Street 2:UNIT F
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4652
Practice Address - Country:US
Practice Address - Phone:714-689-1380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker