Provider Demographics
NPI:1447841283
Name:BUSENBARK, MADISEN ELISE
Entity type:Individual
Prefix:
First Name:MADISEN
Middle Name:ELISE
Last Name:BUSENBARK
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 1:5094 E BIG SKY WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-4878
Mailing Address - Country:US
Mailing Address - Phone:435-256-0056
Mailing Address - Fax:
Practice Address - Street 1:10432 S 4000 W STE B105
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-5729
Practice Address - Country:US
Practice Address - Phone:435-610-1676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12086440-3904101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health