Provider Demographics
NPI:1912286782
Name:LUENEBURG, DEIDRE MARIE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:MARIE
Last Name:LUENEBURG
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MISS
Other - First Name:DEIDRE
Other - Middle Name:MARIE
Other - Last Name:SERAFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:4121 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2628
Mailing Address - Country:US
Mailing Address - Phone:563-583-4003
Mailing Address - Fax:563-583-4737
Practice Address - Street 1:4121 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2628
Practice Address - Country:US
Practice Address - Phone:563-583-4003
Practice Address - Fax:563-583-4737
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002029235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665950Medicaid
IA166595Medicare PIN