Provider Demographics
NPI:1043864887
Name:BURSELL, VICTORIA (SLP-A)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:BURSELL
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 W PRESIDIO DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-9172
Mailing Address - Country:US
Mailing Address - Phone:480-789-0074
Mailing Address - Fax:
Practice Address - Street 1:221 E KIMBERLY WAY
Practice Address - Street 2:
Practice Address - City:RIMROCK
Practice Address - State:AZ
Practice Address - Zip Code:86335-6315
Practice Address - Country:US
Practice Address - Phone:928-773-0896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA119812355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant