Provider Demographics
NPI:1053437418
Name:BURBANK, MIRANDA (SLP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:BURBANK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 TUCKERS RUN
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-8213
Mailing Address - Country:US
Mailing Address - Phone:304-927-4056
Mailing Address - Fax:
Practice Address - Street 1:200 S RITCHIE AVE
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164-1721
Practice Address - Country:US
Practice Address - Phone:304-273-9385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0780235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist