Provider Demographics
NPI:1053463349
Name:BURD, GWYN O'NEAL (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:GWYN
Middle Name:O'NEAL
Last Name:BURD
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 1:3303 BANDOLINA DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-6738
Mailing Address - Country:US
Mailing Address - Phone:505-627-9938
Mailing Address - Fax:
Practice Address - Street 1:300 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4636
Practice Address - Country:US
Practice Address - Phone:505-627-2875
Practice Address - Fax:505-627-2544
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3474235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12051047Medicaid