Provider Demographics
NPI:1942020128
Name:MUDGE, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MUDGE
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 1:21425 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-9707
Mailing Address - Country:US
Mailing Address - Phone:262-878-2411
Mailing Address - Fax:
Practice Address - Street 1:21425 SPRING ST
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-9707
Practice Address - Country:US
Practice Address - Phone:262-878-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.008106235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist