Provider Demographics
NPI:1679917736
Name:BURRIS, KELLY (LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BURRIS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 CAMINO DE LOS MARES
Mailing Address - Street 2:241
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673
Mailing Address - Country:US
Mailing Address - Phone:949-391-8278
Mailing Address - Fax:
Practice Address - Street 1:657 CAMINO DE LOS MARES
Practice Address - Street 2:241
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673
Practice Address - Country:US
Practice Address - Phone:949-391-8278
Practice Address - Fax:949-391-8278
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor