Provider Demographics
NPI:1972694248
Name:BURKHOUSE, KELLY (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BURKHOUSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3787 WESTMAN RD
Mailing Address - Street 2:
Mailing Address - City:BEMUS POINT
Mailing Address - State:NY
Mailing Address - Zip Code:14712-9511
Mailing Address - Country:US
Mailing Address - Phone:716-499-9245
Mailing Address - Fax:
Practice Address - Street 1:500 PINE ST STE 3
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-5331
Practice Address - Country:US
Practice Address - Phone:716-499-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011032103TC0700X
PAPS008930L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01281507Medicaid