Provider Demographics
NPI:1811202435
Name:BUSTLE, MISTY K (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:K
Last Name:BUSTLE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 WILDERNESS TRL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-1309
Mailing Address - Country:US
Mailing Address - Phone:812-592-1231
Mailing Address - Fax:
Practice Address - Street 1:1178 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-1251
Practice Address - Country:US
Practice Address - Phone:812-592-1231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46001954A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist