Provider Demographics
NPI:1780120550
Name:BUSQUE, KYRA (LAT ATC)
Entity type:Individual
Prefix:MISS
First Name:KYRA
Middle Name:
Last Name:BUSQUE
Suffix:
Gender:F
Credentials:LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 DOBSON RD
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-5430
Mailing Address - Country:US
Mailing Address - Phone:860-888-2789
Mailing Address - Fax:
Practice Address - Street 1:50 COLLEGE ST
Practice Address - Street 2:KENDALL DANCE AND SPORTS COMPLEX ROOM 126A
Practice Address - City:SOUTH HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01075-1423
Practice Address - Country:US
Practice Address - Phone:413-538-3316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer