Provider Demographics
NPI:1295011039
Name:BURGESS, KRISTIN DANIELLE (MS, OTR/L)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:DANIELLE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2439 EATON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-7424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 W MATTHEWS ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-1309
Practice Address - Country:US
Practice Address - Phone:980-245-2340
Practice Address - Fax:980-245-2333
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8051225XP0200X
SC3879225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7302345Medicaid
SCTH2467Medicaid