Provider Demographics
NPI:1396236790
Name:BUSSIE, ASYA B
Entity type:Individual
Prefix:
First Name:ASYA
Middle Name:B
Last Name:BUSSIE
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 1:3202 BLENHEIM RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-2228
Mailing Address - Country:US
Mailing Address - Phone:443-629-0696
Mailing Address - Fax:
Practice Address - Street 1:2622 LORD BALTIMORE DR STE A
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-2639
Practice Address - Country:US
Practice Address - Phone:443-629-0696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0700X, 251C00000X
MD261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No251C00000XAgenciesDay Training, Developmentally Disabled Services