Provider Demographics
NPI:1548875131
Name:BUSBOOM, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BUSBOOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 CAMEO DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-1645
Mailing Address - Country:US
Mailing Address - Phone:925-389-0005
Mailing Address - Fax:
Practice Address - Street 1:101 SAND CREEK RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2451
Practice Address - Country:US
Practice Address - Phone:925-666-8460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1404360920101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)