Provider Demographics
NPI:1891752150
Name:BURDITT, GAYLE LINDSEY (MA CCC)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:LINDSEY
Last Name:BURDITT
Suffix:
Gender:F
Credentials:MA CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3406 LAURELWOOD LN NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-3722
Mailing Address - Country:US
Mailing Address - Phone:360-866-8093
Mailing Address - Fax:877-612-0969
Practice Address - Street 1:712 TROSPER RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6934
Practice Address - Country:US
Practice Address - Phone:360-866-8093
Practice Address - Fax:877-612-0969
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00001042235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7072739Medicaid
WA35940034OtherTPIN
WA53971002OtherWA STATE LABOR & INDUSTRI