Provider Demographics
NPI:1902041759
Name:BURKETT, KELLY L (MS, CRC, LMHC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:L
Last Name:BURKETT
Suffix:
Gender:F
Credentials:MS, CRC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4939 ERNEST WAY
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041
Mailing Address - Country:US
Mailing Address - Phone:585-739-2492
Mailing Address - Fax:
Practice Address - Street 1:813 FAY RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-3009
Practice Address - Country:US
Practice Address - Phone:315-488-3804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004778101YM0800X
NY00108513225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health