Basic Information
| Provider Information | |||||||||
| NPI: | 1902085665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURKS | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | JANELL | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15507 S NORMANDIE AVE | ||||||||
| Address2: | #113 | ||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902474028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105280125 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4920 AVALON BLVD | ||||||||
| Address2: | BAART | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900114004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232355035 | ||||||||
| FaxNumber: | 3232352023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2007 | ||||||||
| LastUpdateDate: | 10/30/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.