Provider Demographics
NPI:1639481211
Name:BURKLOW, ALISA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:BURKLOW
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 1:4106 MAID STONE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4030
Mailing Address - Country:US
Mailing Address - Phone:337-540-1861
Mailing Address - Fax:
Practice Address - Street 1:4106 MAID STONE DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4030
Practice Address - Country:US
Practice Address - Phone:337-540-1861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3856484235Z00000X
LA6299235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2116401Medicaid