Provider Demographics
NPI:1689919532
Name:BURGESS, TARA MICHELLE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MICHELLE
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 1:1231 GREENWAY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2525
Mailing Address - Country:US
Mailing Address - Phone:972-871-1800
Mailing Address - Fax:972-871-1802
Practice Address - Street 1:1231 GREENWAY DR STE 100
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2525
Practice Address - Country:US
Practice Address - Phone:972-871-1800
Practice Address - Fax:972-871-1802
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX334732355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX207164901Medicaid
TX676535Medicare PIN