Healthcare Provider Details

I. General information

NPI: 1639264138
Provider Name (Legal Business Name): STEPHEN PHILIP BUSHEE ATC, LATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BOSTON COLLEGE, CONTE FORUM-ROOM 124
CHESTNUT HILL MA
01778
US

IV. Provider business mailing address

19 HEARTHSTONE CIRCLE
WAYLAND MA
01778
US

V. Phone/Fax

Practice location:
  • Phone: 617-552-3009
  • Fax: 617-552-9101
Mailing address:
  • Phone: 508-655-3495
  • Fax: 617-552-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number250
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: