Provider Demographics
NPI:1134430903
Name:BURRELL, KODY K
Entity type:Individual
Prefix:
First Name:KODY
Middle Name:K
Last Name:BURRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 S. 500 E. #135
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015
Mailing Address - Country:US
Mailing Address - Phone:801-391-0896
Mailing Address - Fax:
Practice Address - Street 1:370 S 500 E STE 135
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-4001
Practice Address - Country:US
Practice Address - Phone:801-391-0896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor