Provider Demographics
NPI:1972285005
Name:BUSALACCHI, LAUREN (DPT)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BUSALACCHI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:KOEHLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 WILLIAMSBURG PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6856
Mailing Address - Country:US
Mailing Address - Phone:252-634-2626
Mailing Address - Fax:910-353-5610
Practice Address - Street 1:201 WILLIAMSBURG PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6856
Practice Address - Country:US
Practice Address - Phone:252-634-2626
Practice Address - Fax:910-353-5610
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP22494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist