Provider Demographics
NPI:1790825990
Name:BURGESS, LORI (MSTCCCSLP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MSTCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4058 DEERWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1889
Mailing Address - Country:US
Mailing Address - Phone:651-994-9644
Mailing Address - Fax:651-994-8962
Practice Address - Street 1:2795 PILOT KNOB RD
Practice Address - Street 2:SUITE 100
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1119
Practice Address - Country:US
Practice Address - Phone:651-994-9644
Practice Address - Fax:651-994-8962
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7211235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4600338OtherMEDICA
MN963S1BUOtherBCBS
MN500043200Medicaid
MNHP30988OtherHEALTH PARTNERS