Provider Demographics
NPI:1457467706
Name:BURTIS, MARGUERITE HILDA (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:HILDA
Last Name:BURTIS
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 1:5925 FOREST LN
Mailing Address - Street 2:STE 136
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2712
Mailing Address - Country:US
Mailing Address - Phone:972-661-5157
Mailing Address - Fax:972-661-5173
Practice Address - Street 1:5925 FOREST LN
Practice Address - Street 2:STE 136
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2712
Practice Address - Country:US
Practice Address - Phone:972-661-5157
Practice Address - Fax:972-661-5173
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11228235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1503898Medicaid
TX87010TOtherBCBSTX
0004355472OtherAETNA