Provider Demographics
NPI:1215001243
Name:BUSSOLOTTI, MICHELLE A (MFT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:BUSSOLOTTI
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BRIAR HILL DR
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1847
Mailing Address - Country:US
Mailing Address - Phone:860-961-4951
Mailing Address - Fax:
Practice Address - Street 1:489 GOLD STAR HWY STE 209
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6227
Practice Address - Country:US
Practice Address - Phone:860-535-9922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist