Provider Demographics
NPI:1861506305
Name:BUSSEY, GREGORY C (LICSW)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:BUSSEY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 MONTGOMERY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-4156
Mailing Address - Country:US
Mailing Address - Phone:304-224-5099
Mailing Address - Fax:
Practice Address - Street 1:184 UNSER BLVD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4045
Practice Address - Country:US
Practice Address - Phone:505-896-0928
Practice Address - Fax:505-896-0585
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0031470104100000X
WVDP009428701041C0700X
NMI084011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker