Provider Demographics
NPI:1710040407
Name:BUSCH, MICHELE MARIE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MARIE
Last Name:BUSCH
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:PO BOX 496
Mailing Address - Street 2:
Mailing Address - City:CHAMA
Mailing Address - State:NM
Mailing Address - Zip Code:87520-0496
Mailing Address - Country:US
Mailing Address - Phone:505-756-1023
Mailing Address - Fax:
Practice Address - Street 1:STATE ROAD 531
Practice Address - Street 2:
Practice Address - City:TIERRA AMARILLA
Practice Address - State:NM
Practice Address - Zip Code:87575-9701
Practice Address - Country:US
Practice Address - Phone:505-588-7285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3472235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61128007Medicaid