Provider Demographics
NPI:1063930758
Name:BUSSELL, DAVE WESLEY II
Entity type:Individual
Prefix:
First Name:DAVE
Middle Name:WESLEY
Last Name:BUSSELL
Suffix:II
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 1:34841 VETERANS PLZ
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1733
Mailing Address - Country:US
Mailing Address - Phone:313-292-7640
Mailing Address - Fax:313-292-9270
Practice Address - Street 1:34841 VETERANS PLZ
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1733
Practice Address - Country:US
Practice Address - Phone:313-292-7640
Practice Address - Fax:313-292-9270
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-02
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361004483103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical