Healthcare Provider Details

I. General information

NPI: 1063930758
Provider Name (Legal Business Name): DAVE WESLEY BUSSELL II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2017
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34841 VETERANS PLZ
WAYNE MI
48184-1733
US

IV. Provider business mailing address

34841 VETERANS PLZ
WAYNE MI
48184-1733
US

V. Phone/Fax

Practice location:
  • Phone: 313-292-7640
  • Fax: 313-292-9270
Mailing address:
  • Phone: 313-292-7640
  • Fax: 313-292-9270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6361004483
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: