Provider Demographics
NPI:1568818797
Name:BUSSERT, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BUSSERT
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 1:16 SARATOGA BRIDGES BLVD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-6236
Mailing Address - Country:US
Mailing Address - Phone:518-587-0723
Mailing Address - Fax:518-583-9607
Practice Address - Street 1:16 SARATOGA BRIDGES BLVD
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-6236
Practice Address - Country:US
Practice Address - Phone:518-587-0723
Practice Address - Fax:518-583-9607
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003872-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant