Healthcare Provider Details

I. General information

NPI: 1144287004
Provider Name (Legal Business Name): LINDA FAYE WELLS BUSCH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LIELMANIS AVE
HURLBURT FLD FL
32544-5613
US

IV. Provider business mailing address

PO BOX 9432
HURLBURT FLD FL
32544-9432
US

V. Phone/Fax

Practice location:
  • Phone: 850-881-4237
  • Fax: 850-881-5239
Mailing address:
  • Phone: 850-881-4237
  • Fax: 850-881-5239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3364
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: