Provider Demographics
NPI:1558642710
Name:BURRITT, GRACE ALETHA (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:ALETHA
Last Name:BURRITT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5170 BROCKWAY LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1704
Mailing Address - Country:US
Mailing Address - Phone:315-446-3720
Mailing Address - Fax:
Practice Address - Street 1:725 HARRISON ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2395
Practice Address - Country:US
Practice Address - Phone:315-435-4202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0089981235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0089981Medicaid
NY01019552Medicare Oscar/Certification