Provider Demographics
NPI:1982146932
Name:BURGESS, BETHANY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:HOPE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:508 S DONALD ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:TX
Mailing Address - Zip Code:76380-2812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:508 S DONALD ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:TX
Practice Address - Zip Code:76380-2812
Practice Address - Country:US
Practice Address - Phone:940-256-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111375235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist