Provider Demographics
NPI:1902085665
Name:BURKS, KRYSTAL JANELL
Entity Type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:JANELL
Last Name:BURKS
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 1:15507 S NORMANDIE AVE
Mailing Address - Street 2:#113
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4028
Mailing Address - Country:US
Mailing Address - Phone:310-528-0125
Mailing Address - Fax:
Practice Address - Street 1:4920 AVALON BLVD
Practice Address - Street 2:BAART
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-4004
Practice Address - Country:US
Practice Address - Phone:323-235-5035
Practice Address - Fax:323-235-2023
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist