Provider Demographics
NPI:1043502685
Name:BURNS, KELLI DAWN (LPCC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:DAWN
Last Name:BURNS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:DAWN
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3445 SWAN RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-9413
Mailing Address - Country:US
Mailing Address - Phone:419-491-0830
Mailing Address - Fax:
Practice Address - Street 1:1045 KLOTZ RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-4820
Practice Address - Country:US
Practice Address - Phone:419-352-7588
Practice Address - Fax:419-354-4977
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-13
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0008147101YP2500X
OHE.1800918101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC0008147OtherSTATE OF OHIO COUNSELOR AND SOCIAL WORKER BOARD
OHE.1800918OtherSTATE OF OHIO COUNSELOR, SOCIAL WORKER, MARRIAGE AND FAMILY THERAPIST BOARD