Provider Demographics
NPI:1265087407
Name:BURGESS, MCKAYLA JO (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MCKAYLA
Middle Name:JO
Last Name:BURGESS
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 1:1318 PEA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-5670
Mailing Address - Country:US
Mailing Address - Phone:304-840-5259
Mailing Address - Fax:
Practice Address - Street 1:112 MELLON ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3536
Practice Address - Country:US
Practice Address - Phone:304-255-5263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-2120235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist