Provider Demographics
NPI:1558645945
Name:BURNSIDE, DAWN (SLP)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:BURNSIDE
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:PO BOX 2385
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5885
Mailing Address - Country:US
Mailing Address - Phone:219-764-4888
Mailing Address - Fax:219-764-7676
Practice Address - Street 1:332 W 806 N
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-7973
Practice Address - Country:US
Practice Address - Phone:219-764-4888
Practice Address - Fax:219-764-7676
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46002247A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist