Provider Demographics
NPI:1790885077
Name:BURCZEUSKI, TARA H (MS ED, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:H
Last Name:BURCZEUSKI
Suffix:
Gender:F
Credentials:MS ED, CCC/SLP
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:H
Other - Last Name:FIORELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS ED, CCC/SLP
Mailing Address - Street 1:133 AVIATION RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-8206
Mailing Address - Country:US
Mailing Address - Phone:518-798-0170
Mailing Address - Fax:
Practice Address - Street 1:133 AVIATION RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-8206
Practice Address - Country:US
Practice Address - Phone:518-798-0170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011232-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00752456Medicaid