Provider Demographics
NPI:1073382586
Name:BUSH, MATTIE GATES (LMFT)
Entity Type:Individual
Prefix:MS
First Name:MATTIE
Middle Name:GATES
Last Name:BUSH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MRS
Other - First Name:MATTIE
Other - Middle Name:GLEN
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NA
Mailing Address - Street 1:37 SHARP ST
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-1721
Mailing Address - Country:US
Mailing Address - Phone:478-361-9774
Mailing Address - Fax:
Practice Address - Street 1:37 SHARP ST
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:GA
Practice Address - Zip Code:31029-1721
Practice Address - Country:US
Practice Address - Phone:478-361-9774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000773101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty