Healthcare Provider Details

I. General information

NPI: 1902495559
Provider Name (Legal Business Name): SAMANTHA KELLY BURCH M.ED, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2021
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 TWINRIDGE LN STE A
NORTH CHESTERFIELD VA
23235-5200
US

IV. Provider business mailing address

206 TWINRIDGE LN STE A
NORTH CHESTERFIELD VA
23235-5200
US

V. Phone/Fax

Practice location:
  • Phone: 804-323-9060
  • Fax: 804-323-7576
Mailing address:
  • Phone: 804-323-9060
  • Fax: 804-323-7576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202007259
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: