Provider Demographics
NPI:1780192856
Name:BURSLEY, KERRY ALICE CHRYSALIS (LPC)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:ALICE CHRYSALIS
Last Name:BURSLEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:ALICE
Other - Last Name:EARTHSOUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:501 N SUNSET LN
Practice Address - Street 2:
Practice Address - City:RAYMORE
Practice Address - State:MO
Practice Address - Zip Code:64083-9402
Practice Address - Country:US
Practice Address - Phone:844-853-8937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017042943101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional