Provider Demographics
NPI:1548342439
Name:BUSNENGO, EVELYN J (LICSW)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:J
Last Name:BUSNENGO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SANDWICH RD
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571-1637
Mailing Address - Country:US
Mailing Address - Phone:508-295-3600
Mailing Address - Fax:
Practice Address - Street 1:215 SANDWICH RD
Practice Address - Street 2:
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571-1637
Practice Address - Country:US
Practice Address - Phone:508-295-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110781101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABUP22468Medicare ID - Type Unspecified