Basic Information
| Provider Information | |||||||||
| NPI: | 1619275807 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSKIRK | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR BLDG B | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11143 PARKVIEW PLAZA DR STE 207 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603738000 | ||||||||
| FaxNumber: | 2602665379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2011 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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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 | 103G00000X | 20041648A | IN | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.