Provider Demographics
NPI:1588168041
Name:BUDDELMEYER, MARK S (LICDC, LPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:BUDDELMEYER
Suffix:
Gender:M
Credentials:LICDC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 STONERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-8956
Mailing Address - Country:US
Mailing Address - Phone:740-500-1391
Mailing Address - Fax:740-500-1395
Practice Address - Street 1:1875 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-8956
Practice Address - Country:US
Practice Address - Phone:740-500-1391
Practice Address - Fax:740-500-1395
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1300423101YM0800X
OH136175T00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist