Provider Demographics
NPI:1558610089
Name:BUSICK, DANIELLE (LMT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:BUSICK
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 1:1742 NE SARATOGA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-4732
Mailing Address - Country:US
Mailing Address - Phone:253-740-8257
Mailing Address - Fax:
Practice Address - Street 1:4224 NE HALSEY ST
Practice Address - Street 2:325
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1538
Practice Address - Country:US
Practice Address - Phone:503-505-6181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19066225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist