Basic Information
| Provider Information | |||||||||
| NPI: | 1003805334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSSARD | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 GROFF RD | ||||||||
| Address2: | |||||||||
| City: | HORSEHEADS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148457925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077380733 | ||||||||
| FaxNumber: | 6075628854 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 GROFF RD | ||||||||
| Address2: | |||||||||
| City: | HORSEHEADS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148457925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077380733 | ||||||||
| FaxNumber: | 6075628854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R 053342-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 01751775 | 05 | NY | MEDICAID |