Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker |
NPI | 1003164187 |
---|---|
Provider Name | Amy Burnside |
First Address | Gilbert, AZ 85295-0764 |
Second Address | Tempe, AZ 85282-5581 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2012 |
Last Update Date | 30/12/2019 |