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General NPI Number Information
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NPI Number | 1194201848
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Entity Type | Individual
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Provider Name | MRS. ISABELLA RAE ECCLESTON BUSCH
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Gender | Female
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Dates
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Enumeration Date | 07/16/2018
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Last Update Date | 08/23/2022
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Provider Practice Location Address
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Address Line | 51 SCHOOL ST
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City | LAKE RONKONKOMA
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State | NY
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Zip | 11779-2298
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Country | US
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Telephone | 631-471-1300
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Fax |
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Provider Business Mailing Address
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Address Line | 2615 UNION BLVD
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City | ISLIP
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State | NY
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Zip | 11751-3207
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Country | US
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Telephone | 631-383-8686
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 028942
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License Number State | NY
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