Healthcare Provider Details

I. General information

NPI: 1912379330
Provider Name (Legal Business Name): ABIGAIL TRESE BURKLOW M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2015
Last Update Date: 10/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S TYLER ST SUITE 805
AMARILLO TX
79101-2353
US

IV. Provider business mailing address

1310 23RD ST APT 703
CANYON TX
79015-5328
US

V. Phone/Fax

Practice location:
  • Phone: 806-553-7780
  • Fax:
Mailing address:
  • Phone: 806-654-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number109014
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: