Provider Demographics
NPI:1053343699
Name:BUSCH, DAVID T (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:T
Last Name:BUSCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:740 LITTLE ROCK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CHERRYLOG
Mailing Address - State:GA
Mailing Address - Zip Code:30522-2904
Mailing Address - Country:US
Mailing Address - Phone:706-635-8200
Mailing Address - Fax:706-635-8201
Practice Address - Street 1:740 LITTLE ROCK CREEK RD
Practice Address - Street 2:
Practice Address - City:CHERRYLOG
Practice Address - State:GA
Practice Address - Zip Code:30522-2904
Practice Address - Country:US
Practice Address - Phone:706-635-8200
Practice Address - Fax:706-635-8201
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1377103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBCGDMedicare ID - Type Unspecified