Provider Demographics
NPI:1043689011
Name:BUSH, TRACIE L (MA, CKPMT)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:L
Last Name:BUSH
Suffix:
Gender:F
Credentials:MA, CKPMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 COUNTRY WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-1759
Mailing Address - Country:US
Mailing Address - Phone:203-848-7169
Mailing Address - Fax:
Practice Address - Street 1:79 COUNTRY WAY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-1759
Practice Address - Country:US
Practice Address - Phone:203-848-7169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health