Provider Demographics
NPI:1710709183
Name:BURKS, KENDLE ROSAMARIE
Entity type:Individual
Prefix:
First Name:KENDLE
Middle Name:ROSAMARIE
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 1:115 CELTIC CT
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-3299
Mailing Address - Country:US
Mailing Address - Phone:678-749-6688
Mailing Address - Fax:
Practice Address - Street 1:1720 HONEY CREEK CMNS SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-5843
Practice Address - Country:US
Practice Address - Phone:470-998-2467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician