Provider Demographics
NPI:1003805334
Name:BUSSARD, ANNE B (LCSW-R)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:B
Last Name:BUSSARD
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GROFF RD
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-7925
Mailing Address - Country:US
Mailing Address - Phone:607-738-0733
Mailing Address - Fax:607-562-8854
Practice Address - Street 1:17 GROFF RD
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-7925
Practice Address - Country:US
Practice Address - Phone:607-738-0733
Practice Address - Fax:607-562-8854
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR 053342-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01751775Medicaid
NYDD2965Medicare ID - Type Unspecified