Healthcare Provider Details

I. General information

NPI: 1992355481
Provider Name (Legal Business Name): EVERETT BUDDENBERG LICDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 EZZARD CHARLES DR
CINCINNATI OH
45214-2525
US

IV. Provider business mailing address

6498 COTTONTAIL TRL
BURLINGTON KY
41005-9649
US

V. Phone/Fax

Practice location:
  • Phone: 513-381-6672
  • Fax:
Mailing address:
  • Phone: 859-202-4628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2204755
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.161843
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: