Provider Demographics
NPI:1417617028
Name:BUSSEY-MARTIN, SHANTARA L (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANTARA
Middle Name:L
Last Name:BUSSEY-MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 NE MIAMI CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-2063
Mailing Address - Country:US
Mailing Address - Phone:305-567-3398
Mailing Address - Fax:
Practice Address - Street 1:3510 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-3840
Practice Address - Country:US
Practice Address - Phone:954-567-7141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLSW191581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health