Provider Demographics
NPI:1376918235
Name:BUSHMAN, MARISA (AUD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:BUSHMAN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6700 FRANCE AVE S
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1902
Mailing Address - Country:US
Mailing Address - Phone:952-345-3000
Mailing Address - Fax:952-345-6789
Practice Address - Street 1:6700 FRANCE AVE S
Practice Address - Street 2:SUITE 300
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1902
Practice Address - Country:US
Practice Address - Phone:952-345-3000
Practice Address - Fax:952-345-6789
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9586231H00000X
ND1457231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist