Provider Demographics
NPI:1508341256
Name:BUSHATI, ELEA R
Entity Type:Individual
Prefix:
First Name:ELEA
Middle Name:R
Last Name:BUSHATI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 MOUNTAIN VIEW RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071-2230
Mailing Address - Country:US
Mailing Address - Phone:516-469-8155
Mailing Address - Fax:
Practice Address - Street 1:2666 STATE ST STE A3
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06517-2232
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5869225X00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid