Provider Demographics
NPI:1174838569
Name:BUSH, BRENDA J
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 SEYMOUR AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3159
Mailing Address - Country:US
Mailing Address - Phone:307-634-9653
Mailing Address - Fax:
Practice Address - Street 1:2526 SEYMOUR AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3159
Practice Address - Country:US
Practice Address - Phone:307-634-9653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCOTA789224Z00000X
101Y00000X
WYCAP130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)