Provider Demographics
NPI:1588971535
Name:BURKS, AJA (LMSW)
Entity type:Individual
Prefix:
First Name:AJA
Middle Name:
Last Name:BURKS
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 1:17368 W 12 MILE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-6308
Mailing Address - Country:US
Mailing Address - Phone:313-492-8452
Mailing Address - Fax:248-856-3801
Practice Address - Street 1:17368 W 12 MILE RD STE 201
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076
Practice Address - Country:US
Practice Address - Phone:313-492-8452
Practice Address - Fax:248-856-3801
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530Medicaid
IN150074Medicare PIN