Provider Demographics
NPI:1003868514
Name:BUSH, SHANE (PHD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 HAWKINS AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-9600
Mailing Address - Country:US
Mailing Address - Phone:631-334-7884
Mailing Address - Fax:631-980-3715
Practice Address - Street 1:290 HAWKINS AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-9600
Practice Address - Country:US
Practice Address - Phone:631-334-7884
Practice Address - Fax:631-980-3715
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012998-2103TC0700X
NY012998103G00000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation