Provider Demographics
NPI:1376720680
Name:BUSH, KIMBERLY (MFA, ATR-BC, LCAT)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:MFA, ATR-BC, LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CAMBRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-1908
Mailing Address - Country:US
Mailing Address - Phone:917-406-9955
Mailing Address - Fax:
Practice Address - Street 1:16 CAMBRIDGE PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-1908
Practice Address - Country:US
Practice Address - Phone:917-406-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102L00000X
NY0697221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst