Basic Information
| Provider Information | |||||||||
| NPI: | 1568023349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | ALPHIA | ||||||||
| MiddleName: | RAMONA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURGESS | ||||||||
| OtherFirstName: | ALPHIA | ||||||||
| OtherMiddleName: | RAMONA | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LLBSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19620 SHADY LANE AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480803381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136571181 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | TEAM WELLNESS CENTER | ||||||||
| Address2: | 2925 RUSSELL STREET | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133965300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2019 | ||||||||
| LastUpdateDate: | 06/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.