Provider Demographics
NPI:1043357130
Name:BUSCH, KRISTINE A (PT)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:A
Last Name:BUSCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BELGIUM
Mailing Address - State:WI
Mailing Address - Zip Code:53004-9305
Mailing Address - Country:US
Mailing Address - Phone:847-971-7999
Mailing Address - Fax:
Practice Address - Street 1:435 1ST ST
Practice Address - Street 2:
Practice Address - City:BELGIUM
Practice Address - State:WI
Practice Address - Zip Code:53004-9305
Practice Address - Country:US
Practice Address - Phone:847-971-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10062-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10062-24OtherPT STATE LIC #
WI40453000Medicaid