Provider Demographics
NPI:1164582771
Name:BUCKINGHAM, DEIDRE M (PTA, LMT)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:M
Last Name:BUCKINGHAM
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 SAINT JOHNS AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53563-1692
Mailing Address - Country:US
Mailing Address - Phone:608-332-1032
Mailing Address - Fax:608-200-3270
Practice Address - Street 1:1915 WINNEBAGO ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5305
Practice Address - Country:US
Practice Address - Phone:608-301-5717
Practice Address - Fax:608-200-3270
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1353-019225200000X
WI724-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant