Provider Demographics
NPI:1578052742
Name:BADGER, ILENE
Entity Type:Individual
Prefix:MS
First Name:ILENE
Middle Name:
Last Name:BADGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 CAPE BRETON DR APT 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-4529
Mailing Address - Country:US
Mailing Address - Phone:919-539-8209
Mailing Address - Fax:
Practice Address - Street 1:5001 CAPE BRETON DR APT 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-4529
Practice Address - Country:US
Practice Address - Phone:919-539-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator