Provider Demographics
NPI:1750541090
Name:BURCH, AUDRA LEIGH MARTIN (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AUDRA
Middle Name:LEIGH MARTIN
Last Name:BURCH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 WELBY WAY STE 5
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4595
Mailing Address - Country:US
Mailing Address - Phone:850-325-6301
Mailing Address - Fax:850-325-6302
Practice Address - Street 1:1915 WELBY WAY STE 5
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4595
Practice Address - Country:US
Practice Address - Phone:850-325-6301
Practice Address - Fax:850-325-6302
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8482235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist