Provider Demographics
NPI:1215531801
Name:BUDDE, STACY LEANNE
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LEANNE
Last Name:BUDDE
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 1:633 S CENTER S
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5831
Mailing Address - Country:US
Mailing Address - Phone:909-831-0666
Mailing Address - Fax:
Practice Address - Street 1:5870 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-5831
Practice Address - Country:US
Practice Address - Phone:951-683-6596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)