1154308195 NPI number — DR. RICHARD O. BUSH PH.D., L.P.C.

Table of content: CAITLYN RENEE IVESTER (NPI 1396221628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154308195 NPI number — DR. RICHARD O. BUSH PH.D., L.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSH
Provider First Name:
RICHARD
Provider Middle Name:
O.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., L.P.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154308195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1437 ROLLINS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75013-2930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-727-1400
Provider Business Mailing Address Fax Number:
214-547-9151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1437 ROLLINS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75013-2930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-727-1400
Provider Business Practice Location Address Fax Number:
214-547-9151
Provider Enumeration Date:
12/30/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  19951 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 19951 . This is a "LICENSED PROFESSIONAL COU" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: R865 . This is a "N.B.C.C.H." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".