MEDICARE: CAMERON IMANI BURRIS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	SW19527	FL

General Provider Information

NPI Number	:	1780331793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMERON IMANI BURRIS LCSW

Provider Business Mailing Address
First Line	:	PO BOX 21164
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33742-1164
Country	:	US
Telephone Number	:	727-279-5984
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 GANDY BLVD N # 21164
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33702-2409
Country	:	US
Telephone Number	:	727-279-5984
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2022
Last Update Date	:	03/09/2022

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