Provider Demographics
NPI:1497522932
Name:BUSLACH, DENISE JEANNE (LMT)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:JEANNE
Last Name:BUSLACH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 PIEDMONT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-3804
Mailing Address - Country:US
Mailing Address - Phone:949-899-5277
Mailing Address - Fax:
Practice Address - Street 1:20321 SW ACACIA ST STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1762
Practice Address - Country:US
Practice Address - Phone:949-899-5277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84900225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty