Provider Demographics
NPI:1881911139
Name:BURKS, BRIAN A (SLP)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:A
Last Name:BURKS
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 N WHITE SANDS BLVD
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6246
Mailing Address - Country:US
Mailing Address - Phone:575-437-3505
Mailing Address - Fax:575-439-4406
Practice Address - Street 1:1900 N WHITE SANDS BLVD
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6246
Practice Address - Country:US
Practice Address - Phone:575-437-3505
Practice Address - Fax:575-439-4406
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3682235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist