Provider Demographics
NPI:1619991940
Name:BURCHAM, MANDI LEANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:LEANN
Last Name:BURCHAM
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 1:2801 WELLINGTON CIR APT E3
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-3908
Mailing Address - Country:US
Mailing Address - Phone:479-790-0120
Mailing Address - Fax:
Practice Address - Street 1:2801 WELLINGTON CIR APT E3
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-3908
Practice Address - Country:US
Practice Address - Phone:479-790-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#2238235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y071OtherBC/BS