Healthcare Provider Details

I. General information

NPI: 1710040407
Provider Name (Legal Business Name): MICHELE MARIE BUSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STATE ROAD 531
TIERRA AMARILLA NM
87575-9701
US

IV. Provider business mailing address

PO BOX 496
CHAMA NM
87520-0496
US

V. Phone/Fax

Practice location:
  • Phone: 505-588-7285
  • Fax:
Mailing address:
  • Phone: 505-756-1023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3472
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: