Healthcare Provider Details

I. General information

NPI: 1053063255
Provider Name (Legal Business Name): CARRIE BURGESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 COLONIAL BLVD STE 2
FORT MYERS FL
33966-1062
US

IV. Provider business mailing address

8863 FALCON POINTE LOOP
FORT MYERS FL
33912-1472
US

V. Phone/Fax

Practice location:
  • Phone: 239-351-3715
  • Fax:
Mailing address:
  • Phone: 239-529-8682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-26-17084
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: