Provider Demographics
NPI:1023456548
Name:BURA, STACY GAYLE (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:GAYLE
Last Name:BURA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4870 LA MOYNE LANE
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022
Mailing Address - Country:US
Mailing Address - Phone:404-641-5091
Mailing Address - Fax:
Practice Address - Street 1:5050 RESEARCH COURT
Practice Address - Street 2:STE. 800
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024
Practice Address - Country:US
Practice Address - Phone:770-205-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008054235Z00000X
GA14065097235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist