Healthcare Provider Details

I. General information

NPI: 1588776769
Provider Name (Legal Business Name): MARCY L BUSELLI ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 BABCOCK ST
BOSTON MA
02215-1003
US

IV. Provider business mailing address

19 CHESTER ST APT 3
ALLSTON MA
02134-3025
US

V. Phone/Fax

Practice location:
  • Phone: 617-694-9767
  • Fax:
Mailing address:
  • Phone: 203-565-6953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1759
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: