Provider Demographics
NPI:1417245051
Name:BUSCH, CARLY CHRISTINE (AUD)
Entity Type:Individual
Prefix:MS
First Name:CARLY
Middle Name:CHRISTINE
Last Name:BUSCH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:CHRISTINE
Other - Last Name:KEMPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4801 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4801 VETERANS DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2015
Practice Address - Country:US
Practice Address - Phone:320-252-1670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8792231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist