Provider Demographics
NPI:1235769647
Name:BUSCH, KRISTEN KAY (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:KAY
Last Name:BUSCH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-2964
Mailing Address - Country:US
Mailing Address - Phone:618-606-3251
Mailing Address - Fax:
Practice Address - Street 1:281 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-2964
Practice Address - Country:US
Practice Address - Phone:618-606-3251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.024593225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist