Healthcare Provider Details

I. General information

NPI: 1962326819
Provider Name (Legal Business Name): KATHLEEN GRACE BURRUSS LCMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE BURRUSS LCMHCA

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2499 HENNING DR
WINSTON SALEM NC
27106-4558
US

IV. Provider business mailing address

1230 POLO RD
WINSTON SALEM NC
27106-3925
US

V. Phone/Fax

Practice location:
  • Phone: 336-298-6818
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA23338
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: