Provider Demographics
NPI:1164197703
Name:BUSHNELL, TIFFANY R (AMFT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:R
Last Name:BUSHNELL
Suffix:
Gender:F
Credentials:AMFT
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 691388
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-9388
Mailing Address - Country:US
Mailing Address - Phone:310-902-7137
Mailing Address - Fax:
Practice Address - Street 1:3808 W RIVERSIDE DR STE 400
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-5301
Practice Address - Country:US
Practice Address - Phone:323-609-7805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118666106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist