Basic Information
Provider Information | |||||||||
NPI: | 1598994527 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUSSANICH | ||||||||
FirstName: | MAUREEN | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9 BLANDFORD CT | ||||||||
Address2: |   | ||||||||
City: | WAYNE | ||||||||
State: | NJ | ||||||||
PostalCode: | 074702977 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9736948270 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 242 W PARKWAY | ||||||||
Address2: |   | ||||||||
City: | POMPTON PLAINS | ||||||||
State: | NJ | ||||||||
PostalCode: | 074441029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9738310717 | ||||||||
FaxNumber: | 9738310733 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2009 | ||||||||
LastUpdateDate: | 07/13/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | QA005971 | NJ | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.