Provider Demographics
NPI:1255539466
Name:BUSBOOM, MAVIE JEAN (MA)
Entity type:Individual
Prefix:MRS
First Name:MAVIE
Middle Name:JEAN
Last Name:BUSBOOM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:MAVIE
Other - Middle Name:JEAN
Other - Last Name:DAUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:650 S PEORIA
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-4429
Mailing Address - Country:US
Mailing Address - Phone:918-587-9471
Mailing Address - Fax:918-560-0137
Practice Address - Street 1:3604 N CINCINNATI
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-1536
Practice Address - Country:US
Practice Address - Phone:918-425-4200
Practice Address - Fax:918-425-4202
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator