Healthcare Provider Details

I. General information

NPI: 1174700926
Provider Name (Legal Business Name): JEFFREY L BUSBY MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MERRICK ST
WORCESTER MA
01609-1937
US

IV. Provider business mailing address

105 MERRICK ST
WORCESTER MA
01609-1937
US

V. Phone/Fax

Practice location:
  • Phone: 508-797-6100
  • Fax: 508-753-5051
Mailing address:
  • Phone: 508-797-6100
  • Fax: 508-753-5051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierM18684
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS
# 2
Identifier1308785
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 3
Identifier1306421
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: