Provider Demographics
NPI:1780331793
Name:BURRIS, CAMERON IMANI (LCSW)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:IMANI
Last Name:BURRIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21164
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33742-1164
Mailing Address - Country:US
Mailing Address - Phone:727-279-5984
Mailing Address - Fax:
Practice Address - Street 1:1201 GANDY BLVD N # 21164
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-2409
Practice Address - Country:US
Practice Address - Phone:727-279-5984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW19527101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health