Provider Demographics
NPI:1942044334
Name:BURT, HALLE JADE
Entity type:Individual
Prefix:
First Name:HALLE
Middle Name:JADE
Last Name:BURT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17866 N ADAMS HTS
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:NY
Mailing Address - Zip Code:13605-2355
Mailing Address - Country:US
Mailing Address - Phone:315-777-3833
Mailing Address - Fax:
Practice Address - Street 1:20104 ARSENAL STREET RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5555
Practice Address - Country:US
Practice Address - Phone:315-779-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist