Healthcare Provider Details

I. General information

NPI: 1265154611
Provider Name (Legal Business Name): MALLORY VAUGHN BUKAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W INDEPENDENCE BLVD
MOUNT AIRY NC
27030-3576
US

IV. Provider business mailing address

6835 RIDGE RD
TOBACCOVILLE NC
27050-9731
US

V. Phone/Fax

Practice location:
  • Phone: 855-983-0488
  • Fax:
Mailing address:
  • Phone: 704-495-5342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30001123
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: