Provider Demographics
NPI:1407009061
Name:RASTLEY, PAULA RENATE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:RENATE
Last Name:RASTLEY
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 1:16783 IVES STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5312
Mailing Address - Country:US
Mailing Address - Phone:315-788-5377
Mailing Address - Fax:315-788-5373
Practice Address - Street 1:16783 IVES STREET EXT
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5312
Practice Address - Country:US
Practice Address - Phone:315-788-5377
Practice Address - Fax:315-788-5373
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010703-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist