Provider Demographics
NPI:1063063980
Name:BURGESS, DANIELLE (REG CLIN SW INTERN)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:REG CLIN SW INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3577 SW CORPORATE PKWY
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-8153
Mailing Address - Country:US
Mailing Address - Phone:772-220-3439
Mailing Address - Fax:772-220-3484
Practice Address - Street 1:3577 SW CORPORATE PKWY
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-8153
Practice Address - Country:US
Practice Address - Phone:772-220-3439
Practice Address - Fax:772-220-3484
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW13977104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker