Provider Demographics
NPI:1376795831
Name:BELTON-BOURJOLLY, GRETTA (SLP)
Entity Type:Individual
Prefix:MRS
First Name:GRETTA
Middle Name:
Last Name:BELTON-BOURJOLLY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11714 170TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-2212
Mailing Address - Country:US
Mailing Address - Phone:718-527-0362
Mailing Address - Fax:718-527-0362
Practice Address - Street 1:11714 170TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-2212
Practice Address - Country:US
Practice Address - Phone:718-527-0362
Practice Address - Fax:718-527-0362
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009151235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist