Provider Demographics
NPI:1750911640
Name:BUBOLZ, KATHLEEN HATKE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:HATKE
Last Name:BUBOLZ
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2949 4TH ST SE UNIT 123
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3883
Mailing Address - Country:US
Mailing Address - Phone:636-577-3073
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3799
Practice Address - Country:US
Practice Address - Phone:612-863-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10269235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist