Provider Demographics
NPI:1023130523
Name:BUFFETT, DEBRA
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:BUFFETT
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 1:5454 S SHORE DR APT 922
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5995
Mailing Address - Country:US
Mailing Address - Phone:773-213-8495
Mailing Address - Fax:
Practice Address - Street 1:5454 S SHORE DR APT 922
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5995
Practice Address - Country:US
Practice Address - Phone:773-213-8495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2170001072355S0801X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL103034Medicaid
IL147715Medicare ID - Type Unspecified