Provider Demographics
NPI:1043413701
Name:BUSSELL, DALE THEODORE (PT)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:THEODORE
Last Name:BUSSELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 E GRANT RD
Mailing Address - Street 2:UNIT #6
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2749
Mailing Address - Country:US
Mailing Address - Phone:520-512-1038
Mailing Address - Fax:
Practice Address - Street 1:530 IOWA AVE SE
Practice Address - Street 2:STE.105
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-2864
Practice Address - Country:US
Practice Address - Phone:605-352-2169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0031225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist