Provider Demographics
NPI:1871244137
Name:BURNINGHAM, KAYLA (LMFT)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:BURNINGHAM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 HUMBOLDT ST APT 3L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-2850
Mailing Address - Country:US
Mailing Address - Phone:801-995-8313
Mailing Address - Fax:
Practice Address - Street 1:1611 COUNTY ROAD B W STE 204
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4053
Practice Address - Country:US
Practice Address - Phone:801-995-8313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3959106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist