Provider Demographics
NPI:1114658812
Name:BURGESS, HEATHER CAROLINE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:CAROLINE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N ROBINSON DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-5966
Mailing Address - Country:US
Mailing Address - Phone:770-875-3037
Mailing Address - Fax:
Practice Address - Street 1:120 N ROBINSON DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-5966
Practice Address - Country:US
Practice Address - Phone:770-875-3037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
GAPCET003551235Z00000X
GASLP012578235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist