Provider Demographics
NPI:1407258668
Name:BUSSEY, VICTORIA JEAN
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:JEAN
Last Name:BUSSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:VICTORIA
Other - Middle Name:JEAN
Other - Last Name:LASTINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 N MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CHIEFLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32626-0870
Mailing Address - Country:US
Mailing Address - Phone:352-490-7500
Mailing Address - Fax:
Practice Address - Street 1:220 N MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-0870
Practice Address - Country:US
Practice Address - Phone:352-490-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13910235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014097800Medicaid