Provider Demographics
NPI:1497067961
Name:BURKE, KELLY DAWN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DAWN
Last Name:BURKE
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 1:6721 CLOVERCREST DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5403
Mailing Address - Country:US
Mailing Address - Phone:859-494-1420
Mailing Address - Fax:
Practice Address - Street 1:3514 STELLHORN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4631
Practice Address - Country:US
Practice Address - Phone:859-267-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty