Provider Demographics
NPI:1154682631
Name:BUSCH, FRED (PHD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:
Last Name:BUSCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 ELIOT ST
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-1447
Mailing Address - Country:US
Mailing Address - Phone:617-232-5674
Mailing Address - Fax:
Practice Address - Street 1:246 ELIOT ST
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-1447
Practice Address - Country:US
Practice Address - Phone:617-232-5674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7649103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist