Provider Demographics
NPI:1861180366
Name:BURRELL, KLOE JASMINE
Entity type:Individual
Prefix:
First Name:KLOE
Middle Name:JASMINE
Last Name:BURRELL
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 1:32216 BENBOW DR E
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-9083
Mailing Address - Country:US
Mailing Address - Phone:253-304-1214
Mailing Address - Fax:
Practice Address - Street 1:1202 BLACK LAKE BLVD SW
Practice Address - Street 2:SUITE B
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-7208
Practice Address - Country:US
Practice Address - Phone:360-878-8248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-08-17
Deactivation Date:2023-08-02
Deactivation Code:
Reactivation Date:2023-08-16
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician