Provider Demographics
NPI:1790197473
Name:KINA BURRUSS
Entity type:Organization
Organization Name:KINA BURRUSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEVELOPMENTAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRUSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-337-2153
Mailing Address - Street 1:1501 DOGWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-4513
Mailing Address - Country:US
Mailing Address - Phone:501-337-2153
Mailing Address - Fax:
Practice Address - Street 1:1501 DOGWOOD TRL
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4513
Practice Address - Country:US
Practice Address - Phone:501-337-2153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR222Q00000X251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services