Provider Demographics
NPI:1922631068
Name:BRUNDIDGE, NATHANIEL (CADC)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:BRUNDIDGE
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 N JOHN WAYNE DR
Mailing Address - Street 2:
Mailing Address - City:WINTERSET
Mailing Address - State:IA
Mailing Address - Zip Code:50273-1501
Mailing Address - Country:US
Mailing Address - Phone:515-462-5967
Mailing Address - Fax:515-462-5981
Practice Address - Street 1:113 N JOHN WAYNE DR
Practice Address - Street 2:
Practice Address - City:WINTERSET
Practice Address - State:IA
Practice Address - Zip Code:50273-1501
Practice Address - Country:US
Practice Address - Phone:515-462-5967
Practice Address - Fax:515-462-5981
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20010101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)