Provider Demographics
NPI:1265789952
Name:BURDEN, KELLY MARIE (MSCJ, LICDC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:BURDEN
Suffix:
Gender:F
Credentials:MSCJ, LICDC
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:RAMPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:222 S ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4804
Mailing Address - Country:US
Mailing Address - Phone:419-308-1119
Mailing Address - Fax:
Practice Address - Street 1:222 S ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4804
Practice Address - Country:US
Practice Address - Phone:419-308-1119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH031041101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)