Basic Information
| Provider Information | |||||||||
| NPI: | 1346813748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSSE | ||||||||
| FirstName: | KENDALL | ||||||||
| MiddleName: | |||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12158 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | MITCHELLVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20721 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12158 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | MITCHELLVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207211932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014302700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2021 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 09344 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | NA | 05 | MD | MEDICAID |