Provider Demographics
NPI:1497376305
Name:BUDDE, MITCHELL R
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:R
Last Name:BUDDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:IA
Mailing Address - Zip Code:52037-9701
Mailing Address - Country:US
Mailing Address - Phone:563-349-3593
Mailing Address - Fax:
Practice Address - Street 1:1575 W 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-2448
Practice Address - Country:US
Practice Address - Phone:563-386-9196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096720235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist