Provider Demographics
NPI:1114967080
Name:BUSH, MICHAEL D (LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:BUSH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 810
Mailing Address - Street 2:
Mailing Address - City:CEDAR BLUFF
Mailing Address - State:VA
Mailing Address - Zip Code:24609-0810
Mailing Address - Country:US
Mailing Address - Phone:276-964-6702
Mailing Address - Fax:276-964-5669
Practice Address - Street 1:160 ROGERS ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-4500
Practice Address - Country:US
Practice Address - Phone:276-889-3785
Practice Address - Fax:276-889-2842
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003280101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA173787OtherANTHEM