Provider Demographics
NPI:1164640660
Name:BURDINE, JUDY C (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:C
Last Name:BURDINE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BROWER LN
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-0336
Mailing Address - Country:US
Mailing Address - Phone:903-838-3279
Mailing Address - Fax:
Practice Address - Street 1:6101 N STATE LINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-5309
Practice Address - Country:US
Practice Address - Phone:903-791-2270
Practice Address - Fax:903-792-0816
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14532235Z00000X
AR477235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX012371Medicaid