Healthcare Provider Details

I. General information

NPI: 1396913505
Provider Name (Legal Business Name): BEVERLY WILSON BURROUGHS MA, CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5469 SOUTHWOOD DR
MEMPHIS TN
38120-1928
US

IV. Provider business mailing address

PO BOX 181291
MEMPHIS TN
38181-1291
US

V. Phone/Fax

Practice location:
  • Phone: 901-761-0021
  • Fax: 901-255-2823
Mailing address:
  • Phone: 901-794-5658
  • Fax: 901-255-2823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP0000000466
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: