1891326690 NPI number — GLADYS T BUSH HEALTH COACH CCMA

Table of content: (NPI 1861660268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891326690 NPI number — GLADYS T BUSH HEALTH COACH CCMA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSH
Provider First Name:
GLADYS
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
HEALTH COACH CCMA
Provider Gender Code:
F

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:
1891326690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19284
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71149-0284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-773-0657
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9501 CHASE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118-4619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-773-0657
Provider Business Practice Location Address Fax Number:
318-688-1559
Provider Enumeration Date:
01/30/2020

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: 405300000X , with the licence number:  60312804 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: K5C6Y6M8 . This is a "CCMA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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