Provider Demographics
NPI:1396415154
Name:BUSSEY, KYLE DOMINICK
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DOMINICK
Last Name:BUSSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6327 HUGH RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-9446
Mailing Address - Country:US
Mailing Address - Phone:850-459-5508
Mailing Address - Fax:
Practice Address - Street 1:1290 CELEBRATION BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34747-4692
Practice Address - Country:US
Practice Address - Phone:321-337-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT22173225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist