Provider Demographics
NPI:1790049096
Name:BURT, KELLEY BETH (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:BETH
Last Name:BURT
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 1:7625 HIGHBRIDGE RD APT D8
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-1621
Mailing Address - Country:US
Mailing Address - Phone:315-560-2325
Mailing Address - Fax:
Practice Address - Street 1:110 ELWOOD DAVIS ROAD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088
Practice Address - Country:US
Practice Address - Phone:315-560-2325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021991235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist