Provider Demographics
NPI:1376124628
Name:BUSCH, MYRIAH AMBERELLE
Entity Type:Individual
Prefix:
First Name:MYRIAH
Middle Name:AMBERELLE
Last Name:BUSCH
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 1:441 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALTURAS
Mailing Address - State:CA
Mailing Address - Zip Code:96101-3457
Mailing Address - Country:US
Mailing Address - Phone:530-233-6312
Mailing Address - Fax:530-233-6339
Practice Address - Street 1:441 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTURAS
Practice Address - State:CA
Practice Address - Zip Code:96101-3457
Practice Address - Country:US
Practice Address - Phone:530-233-6312
Practice Address - Fax:530-233-6339
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103TC1900X, 101YM0800X
CA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling