Provider Demographics
NPI:1790232775
Name:BUSACK, ALEXANDRA A
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:A
Last Name:BUSACK
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 1:144 US ROUTE 1 STE 4
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7219
Mailing Address - Country:US
Mailing Address - Phone:207-219-8300
Mailing Address - Fax:207-219-8301
Practice Address - Street 1:144 US ROUTE 1 STE 4
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7219
Practice Address - Country:US
Practice Address - Phone:207-219-8300
Practice Address - Fax:207-219-8301
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEST2585235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist