Provider Demographics
NPI:1598252322
Name:BURGESS, LEILANI (MS, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:LEILANI
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8509 AMISH DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-8421
Mailing Address - Country:US
Mailing Address - Phone:609-846-8781
Mailing Address - Fax:
Practice Address - Street 1:2932 BREEZEWOOD AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5523
Practice Address - Country:US
Practice Address - Phone:910-308-7895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12838235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist