Provider Demographics
NPI:1194951483
Name:BUDWAY, NEALLIE JENNELLE (MS ED)
Entity type:Individual
Prefix:
First Name:NEALLIE
Middle Name:JENNELLE
Last Name:BUDWAY
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 JUDGE HASTY LN
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7320
Mailing Address - Country:US
Mailing Address - Phone:207-885-5367
Mailing Address - Fax:
Practice Address - Street 1:5 JUDGE HASTY LN
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7320
Practice Address - Country:US
Practice Address - Phone:207-885-5367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME208450000Medicaid