Provider Demographics
NPI:1558377697
Name:FARELLA-BUSCH, SUSAN (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FARELLA-BUSCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 ROCKAWAY AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1665
Mailing Address - Country:US
Mailing Address - Phone:516-792-5683
Mailing Address - Fax:516-594-4053
Practice Address - Street 1:1800 ROCKAWAY AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1665
Practice Address - Country:US
Practice Address - Phone:516-792-5683
Practice Address - Fax:516-594-4053
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015749103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV758N1Medicare ID - Type Unspecified
NYQ20371Medicare UPIN