Provider Demographics
NPI:1184198947
Name:BUSHNELL, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BUSHNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2679 WAI WAI PL STE 301
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-8350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2679 WAI WAI PL
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-8196
Practice Address - Country:US
Practice Address - Phone:808-575-2954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician