Provider Demographics
NPI:1447720727
Name:BURNS, DEBRA JOHNSON (MA,CCC-SLP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:JOHNSON
Last Name:BURNS
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 WELTY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4557
Mailing Address - Country:US
Mailing Address - Phone:815-299-4612
Mailing Address - Fax:
Practice Address - Street 1:202 N SHOW PLACE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5351
Practice Address - Country:US
Practice Address - Phone:815-332-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.000668235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist