Provider Demographics
NPI:1396014494
Name:BURTLESS, CATHY ANN (MS, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:CATHY
Middle Name:ANN
Last Name:BURTLESS
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 1:215 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2420
Mailing Address - Country:US
Mailing Address - Phone:631-584-3273
Mailing Address - Fax:
Practice Address - Street 1:99 GREELEY AVE
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2300
Practice Address - Country:US
Practice Address - Phone:631-244-6725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58012720235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY58012720OtherNEW YORK STATE LICENSE