Provider Demographics
NPI:1265154611
Name:BUKAS, MALLORY VAUGHN
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:VAUGHN
Last Name:BUKAS
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 1:6835 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TOBACCOVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27050-9731
Mailing Address - Country:US
Mailing Address - Phone:704-495-5342
Mailing Address - Fax:
Practice Address - Street 1:711 W INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-3576
Practice Address - Country:US
Practice Address - Phone:855-983-0488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30001123235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty