Basic Information
| Provider Information | |||||||||
| NPI: | 1932726171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURDEN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | SMITH | ||||||||
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| Credential: | AUD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | JANEEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043964893 | ||||||||
| Practice Location | |||||||||
| Address1: | 1680 DUNLAWTON AVE | ||||||||
| Address2: | |||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321274754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867568225 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2020 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AY2384 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.