=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215210612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BURKE SPEECH PATHOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2011
-----------------------------------------------------
Last Update Date | 09/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3160 W 29TH AVE
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80211-3757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-503-9474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3160 W 29TH AVE
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80211-3757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-503-9474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MEREDITH BURKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-503-9474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 12127781
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------