Provider Demographics
NPI:1245405968
Name:BUSA-KNEPP, JOHNNA ANN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNA
Middle Name:ANN
Last Name:BUSA-KNEPP
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 15TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-3839
Mailing Address - Country:US
Mailing Address - Phone:806-341-1192
Mailing Address - Fax:
Practice Address - Street 1:412 15TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-3839
Practice Address - Country:US
Practice Address - Phone:806-341-1192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36081103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB150782Medicare PIN