Provider Demographics
NPI:1750662722
Name:BERWALDT, REBECCA SUE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:SUE
Last Name:BERWALDT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7284 ERICA LN
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-4901
Mailing Address - Country:US
Mailing Address - Phone:716-695-3146
Mailing Address - Fax:
Practice Address - Street 1:11 PLEASANT VIEW DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NY
Practice Address - Zip Code:14086-1001
Practice Address - Country:US
Practice Address - Phone:716-686-3280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012033-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist