Healthcare Provider Details

I. General information

NPI: 1699242354
Provider Name (Legal Business Name): KENYATTA CHARLE' BURRIS LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 S COX ST
ASHEBORO NC
27203-6911
US

IV. Provider business mailing address

905 LEWISTON AVE
CHARLOTTE NC
28208-1913
US

V. Phone/Fax

Practice location:
  • Phone: 980-253-2700
  • Fax:
Mailing address:
  • Phone: 980-253-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP021484
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: