Provider Demographics
NPI:1245650753
Name:BURKMAN, KELLY D
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:BURKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 MOUNTAINTOP RD
Mailing Address - Street 2:
Mailing Address - City:REINHOLDS
Mailing Address - State:PA
Mailing Address - Zip Code:17569-9078
Mailing Address - Country:US
Mailing Address - Phone:610-927-3792
Mailing Address - Fax:
Practice Address - Street 1:291 MOUNTAINTOP RD
Practice Address - Street 2:
Practice Address - City:REINHOLDS
Practice Address - State:PA
Practice Address - Zip Code:17569-9078
Practice Address - Country:US
Practice Address - Phone:610-927-3792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL008000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021717420001Medicaid