MEDICARE: BLAKE BUSS

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	225X00000X	Occupational Therapist	23151	CA

General Provider Information

NPI Number	:	1780315051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE BUSS

Provider Business Mailing Address
First Line	:	1807 ORCHARD ST
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-2444
Country	:	US
Telephone Number	:	707-490-5442
Fax Number	:

Provider Business Practice Location Address
First Line	:	1807 ORCHARD ST
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-2444
Country	:	US
Telephone Number	:	707-490-5442
Fax Number	:

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

Provider Enumeration Date	:	06/18/2022
Last Update Date	:	11/10/2022

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Directions to “ BLAKE BUSS ” Practice Location

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