Healthcare Provider Details

I. General information

NPI: 1194201848
Provider Name (Legal Business Name): MRS. ISABELLA RAE ECCLESTON BUSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS ISABELLA RAE RODRIGUEZ ECCLESTON

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 SCHOOL ST
LAKE RONKONKOMA NY
11779-2298
US

IV. Provider business mailing address

2615 UNION BLVD
ISLIP NY
11751-3207
US

V. Phone/Fax

Practice location:
  • Phone: 631-471-1300
  • Fax:
Mailing address:
  • Phone: 631-383-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number028942
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: