Healthcare Provider Details

I. General information

NPI: 1609483627
Provider Name (Legal Business Name): LAKEEYA RENE BURRIS RBT, COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 OLD ALABAMA RD STE 195
ROSWELL GA
30076-2129
US

IV. Provider business mailing address

3500 DEPAUW BLVD STE 3070
INDIANAPOLIS IN
46268-6135
US

V. Phone/Fax

Practice location:
  • Phone: 678-940-1367
  • Fax: 317-520-8200
Mailing address:
  • Phone: 855-324-0885
  • Fax: 317-520-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number16668
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-135036
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: