MEDICARE: MS. KRISTIN DANIELLE BURGESS M.S., OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	8051	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295011039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTIN DANIELLE BURGESS M.S., OTR/L

Provider Business Mailing Address
First Line	:	2439 EATON RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7424
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 W MATTHEWS ST
Second Line	:	SUITE 101
City	:	MATTHEWS
State	:	NC
Zip	:	28105-1309
Country	:	US
Telephone Number	:	980-245-2340
Fax Number	:	980-245-2333

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2011
Last Update Date	:	07/01/2016

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