Provider Demographics
NPI:1225311822
Name:BURKE, SUZANNE CARROLL
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:CARROLL
Last Name:BURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2817
Mailing Address - Country:US
Mailing Address - Phone:716-807-3825
Mailing Address - Fax:
Practice Address - Street 1:455 MEADOW DR
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-2817
Practice Address - Country:US
Practice Address - Phone:716-807-3825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013510-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01377162Medicaid