Healthcare Provider Details

I. General information

NPI: 1497067961
Provider Name (Legal Business Name): KELLY DAWN BURKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3514 STELLHORN RD
FORT WAYNE IN
46815-4631
US

IV. Provider business mailing address

6721 CLOVERCREST DR
FORT WAYNE IN
46815-5403
US

V. Phone/Fax

Practice location:
  • Phone: 859-267-0705
  • Fax:
Mailing address:
  • Phone: 859-494-1420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: