Provider Demographics
NPI:1730288275
Name:BURTON, ELYSE (SLP)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:BURTON
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 1:2371 TANGLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2006
Mailing Address - Country:US
Mailing Address - Phone:770-330-7496
Mailing Address - Fax:
Practice Address - Street 1:2371 TANGLEWOOD RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2006
Practice Address - Country:US
Practice Address - Phone:770-330-7496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASP004756225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner