Provider Demographics
NPI:1003821489
Name:BURNETT, LAURIE MARIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:MARIE
Last Name:BURNETT
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 1:585 WILEY CT
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-5853
Mailing Address - Country:US
Mailing Address - Phone:321-917-0297
Mailing Address - Fax:
Practice Address - Street 1:585 WILEY CT
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-5853
Practice Address - Country:US
Practice Address - Phone:321-917-0297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003834235Z00000X
FLSA 9507235Z00000X
IL146007914235Z00000X
FLSA16056235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00298900Medicaid