Provider Demographics
NPI:1366969602
Name:BURGESS, MARY ELIZABETH (MSP, CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ELIZABETH
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 S PINE ST STE B
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-2673
Mailing Address - Country:US
Mailing Address - Phone:864-591-3484
Mailing Address - Fax:
Practice Address - Street 1:292 S PINE ST STE B
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-2673
Practice Address - Country:US
Practice Address - Phone:864-591-3484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6073235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist