Healthcare Provider Details

I. General information

NPI: 1417617028
Provider Name (Legal Business Name): SHANTARA L. BUSSEY-MARTIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 BISCAYNE BLVD
MIAMI FL
33137-3840
US

IV. Provider business mailing address

5710 NE MIAMI CT
MIAMI FL
33137-2063
US

V. Phone/Fax

Practice location:
  • Phone: 954-567-7141
  • Fax:
Mailing address:
  • Phone: 305-567-3398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW19158
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: