Provider Demographics
NPI:1376180026
Name:BURGESS, VIVIAN PAIGE
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:PAIGE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 APACHE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7432
Mailing Address - Country:US
Mailing Address - Phone:870-336-0238
Mailing Address - Fax:870-336-0238
Practice Address - Street 1:3005 APACHE DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7432
Practice Address - Country:US
Practice Address - Phone:870-336-0238
Practice Address - Fax:870-336-0239
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
AR2009062355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist