Provider Demographics
NPI:1730383159
Name:BURROUGHS, HARRY DALTON JR (MS CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:HARRY
Middle Name:DALTON
Last Name:BURROUGHS
Suffix:JR
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:MR
Other - First Name:ROB
Other - Middle Name:
Other - Last Name:BURROUGHS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:1200 MOUNTAIN CREEK RD
Mailing Address - Street 2:SUITE 380
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-1687
Mailing Address - Country:US
Mailing Address - Phone:423-877-5042
Mailing Address - Fax:423-877-5046
Practice Address - Street 1:1200 MOUNTAIN CREEK RD
Practice Address - Street 2:SUITE 380
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-1687
Practice Address - Country:US
Practice Address - Phone:423-877-5042
Practice Address - Fax:423-877-5046
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP549235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440985Medicaid