Provider Demographics
NPI:1255079091
Name:BURRISS, CRYSTAL (LPCC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:BURRISS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6644
Mailing Address - Fax:
Practice Address - Street 1:8175 N LORETTO RD
Practice Address - Street 2:
Practice Address - City:LORETTO
Practice Address - State:KY
Practice Address - Zip Code:40037-8069
Practice Address - Country:US
Practice Address - Phone:844-435-0900
Practice Address - Fax:270-858-4029
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251049101YM0800X
KY278265101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100293880Medicaid