Provider Demographics
NPI:1902590748
Name:BURRIS, AHSABI-MONIQUE L
Entity Type:Individual
Prefix:
First Name:AHSABI-MONIQUE
Middle Name:L
Last Name:BURRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844 62ND ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2703
Mailing Address - Country:US
Mailing Address - Phone:510-435-4783
Mailing Address - Fax:
Practice Address - Street 1:13925 SAN PABLO AVE STE 203
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3676
Practice Address - Country:US
Practice Address - Phone:510-435-4783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAAMFT141609106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No172V00000XOther Service ProvidersCommunity Health Worker