Provider Demographics
NPI:1619430493
Name:BURDETT, STEVEN D
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:D
Last Name:BURDETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23510 ENCHANTED VW
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-4318
Mailing Address - Country:US
Mailing Address - Phone:505-559-0164
Mailing Address - Fax:505-212-1141
Practice Address - Street 1:13 DOS LOCOS
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-5014
Practice Address - Country:US
Practice Address - Phone:505-559-0164
Practice Address - Fax:505-212-1141
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM531174400000X
NM3285235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16975766Medicaid