MEDICARE: LACY BUSSEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency
2	222Q00000X	Developmental Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710513023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACY BUSSEY

Provider Business Mailing Address
First Line	:	700 N COURTENAY PKWY APT 527
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-5401
Country	:	US
Telephone Number	:	321-750-8447
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 N COURTENAY PKWY APT 527
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-5401
Country	:	US
Telephone Number	:	321-750-8447
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2020
Last Update Date	:	03/18/2020

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Directions to “ LACY BUSSEY ” Practice Location

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