=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033610464
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY BURKE-CHIRICO LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2018
-----------------------------------------------------
Last Update Date | 09/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3372 PEACHTREE RD NE STE 115
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30326-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-532-1238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 CHASE CT
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-1468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-532-1238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW008731
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------