Provider Demographics
NPI:1780381988
Name:BUSAM, JULIA
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:BUSAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BEAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3368
Mailing Address - Country:US
Mailing Address - Phone:636-373-3907
Mailing Address - Fax:
Practice Address - Street 1:2055 CRAIGSHIRE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4036
Practice Address - Country:US
Practice Address - Phone:314-275-0506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-22-201596106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst