Provider Demographics
NPI:1174275929
Name:BUISSERETH, SASHA
Entity Type:Individual
Prefix:
First Name:SASHA
Middle Name:
Last Name:BUISSERETH
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 1:105 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1227
Mailing Address - Country:US
Mailing Address - Phone:917-912-2678
Mailing Address - Fax:
Practice Address - Street 1:669 CASTLETON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2028
Practice Address - Country:US
Practice Address - Phone:718-816-3443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator