Provider Demographics
NPI:1720122930
Name:BURCH, MICHELLE BARBARA (SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BARBARA
Last Name:BURCH
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:PO BOX 110448
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99511-0448
Mailing Address - Country:US
Mailing Address - Phone:907-334-9002
Mailing Address - Fax:
Practice Address - Street 1:600 W 41ST AVE
Practice Address - Street 2:SUITES 102 & 103
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-6601
Practice Address - Country:US
Practice Address - Phone:907-334-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK61235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKSP47561Medicaid