Provider Demographics
NPI:1689052813
Name:BOODRAM, AISHAH (LCSW)
Entity Type:Individual
Prefix:
First Name:AISHAH
Middle Name:
Last Name:BOODRAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AISHA
Other - Middle Name:
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10139 BEACH PORT DR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4413
Mailing Address - Country:US
Mailing Address - Phone:678-472-8964
Mailing Address - Fax:404-487-8907
Practice Address - Street 1:10139 BEACH PORT DR
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4413
Practice Address - Country:US
Practice Address - Phone:618-472-8964
Practice Address - Fax:404-487-8907
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0049351041C0700X
FLSW166551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical