Healthcare Provider Details

I. General information

NPI: 1770608960
Provider Name (Legal Business Name): WILMA J. BUSSE ED.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 TREMONT ST FL 5
BOSTON MA
02108-3916
US

IV. Provider business mailing address

234 E MAIN ST
GLOUCESTER MA
01930-4143
US

V. Phone/Fax

Practice location:
  • Phone: 617-573-8226
  • Fax:
Mailing address:
  • Phone: 978-282-4503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4677
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: