Basic Information
| Provider Information | |||||||||
| NPI: | 1174702682 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSSMAN | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 211 | ||||||||
| Address2: | |||||||||
| City: | MAD RIVER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955520211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076019268 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 321 VAN DUZEN ROAD | ||||||||
| Address2: | |||||||||
| City: | MAD RIVER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075746616 | ||||||||
| FaxNumber: | 7075746523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 06/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3992 | AZ | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 22145 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | LP5708 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | Z125623 | 01 | AZ | MEDICARE PROVIDER NUMBER | OTHER |