Provider Demographics
NPI:1194201848
Name:BUSCH, ISABELLA RAE ECCLESTON
Entity Type:Individual
Prefix:MRS
First Name:ISABELLA
Middle Name:RAE ECCLESTON
Last Name:BUSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ISABELLA
Other - Middle Name:RAE RODRIGUEZ
Other - Last Name:ECCLESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2615 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3207
Mailing Address - Country:US
Mailing Address - Phone:631-383-8686
Mailing Address - Fax:
Practice Address - Street 1:51 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2298
Practice Address - Country:US
Practice Address - Phone:631-471-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY028942235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program