Provider Demographics
NPI:1104579432
Name:BUSSIERE, COREY L (MA, MED/EDS)
Entity type:Individual
Prefix:MR
First Name:COREY
Middle Name:L
Last Name:BUSSIERE
Suffix:
Gender:M
Credentials:MA, MED/EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5749 WESTGATE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5040
Mailing Address - Country:US
Mailing Address - Phone:321-290-0898
Mailing Address - Fax:
Practice Address - Street 1:5749 WESTGATE DR STE 102
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5040
Practice Address - Country:US
Practice Address - Phone:321-290-0898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH22036101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health