Provider Demographics
NPI:1225485758
Name:BURGESS, AISHA (LMSW)
Entity Type:Individual
Prefix:
First Name:AISHA
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 NW 39TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6972
Mailing Address - Country:US
Mailing Address - Phone:352-415-0203
Mailing Address - Fax:352-375-3002
Practice Address - Street 1:5800 NW 39TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6972
Practice Address - Country:US
Practice Address - Phone:352-415-0203
Practice Address - Fax:352-375-3002
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLMSW8850104100000X
FLISW9472104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNLMSW8850OtherTENNESSEE DEPARTMENT OF HEALTH
FLISW9472OtherFLORIDA DEPARTMENT OF HEALTH