Provider Demographics
NPI:1316404627
Name:BUSTIN, DONNA ELLI
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:ELLI
Last Name:BUSTIN
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 1:211 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETERSHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01366-9503
Mailing Address - Country:US
Mailing Address - Phone:978-756-5105
Mailing Address - Fax:978-756-5150
Practice Address - Street 1:211 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PETERSHAM
Practice Address - State:MA
Practice Address - Zip Code:01366-9503
Practice Address - Country:US
Practice Address - Phone:978-756-5105
Practice Address - Fax:978-756-5150
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8980101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health