Provider Demographics
NPI:1043857956
Name:BUSBY, IMANI JORDAN
Entity Type:Individual
Prefix:
First Name:IMANI
Middle Name:JORDAN
Last Name:BUSBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 MACDOUGAL ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-2673
Mailing Address - Country:US
Mailing Address - Phone:516-770-4303
Mailing Address - Fax:
Practice Address - Street 1:118 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-3491
Practice Address - Country:US
Practice Address - Phone:718-552-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist