Provider Demographics
NPI:1114252251
Name:BURNETT-HAISTEN, JUDITH LEA (CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:JUDITH
Middle Name:LEA
Last Name:BURNETT-HAISTEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:LEA
Other - Last Name:BURNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:100 WESTSIDE DR.
Mailing Address - Street 2:CHILD & FAMILY SERVICES
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303
Mailing Address - Country:US
Mailing Address - Phone:334-793-2237
Mailing Address - Fax:334-712-6256
Practice Address - Street 1:100 WESTSIDE DR.
Practice Address - Street 2:CHILD & FAMILY SERVICES
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303
Practice Address - Country:US
Practice Address - Phone:334-793-2237
Practice Address - Fax:334-712-6256
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2963235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL136080Medicaid
AL511-13046OtherBC BS - AL