Provider Demographics
NPI:1851067425
Name:KELLY BURKE, LLC
Entity Type:Organization
Organization Name:KELLY BURKE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHCA
Authorized Official - Phone:260-267-0705
Mailing Address - Street 1:6331 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1547
Mailing Address - Country:US
Mailing Address - Phone:260-267-0705
Mailing Address - Fax:
Practice Address - Street 1:6331 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1547
Practice Address - Country:US
Practice Address - Phone:260-267-0705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty