Provider Demographics
NPI:1225697857
Name:POBURKA, BRUCE JOHN (PHD, CCC-SLP)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:JOHN
Last Name:POBURKA
Suffix:
Gender:M
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 WIECKING CTR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6062
Mailing Address - Country:US
Mailing Address - Phone:507-389-5843
Mailing Address - Fax:507-389-2821
Practice Address - Street 1:150 POST RD.
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6062
Practice Address - Country:US
Practice Address - Phone:507-389-5843
Practice Address - Fax:507-389-2821
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6254235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist