Provider Demographics
NPI:1396398905
Name:BUSH, ALYSSA ANN (CDCA170942)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ANN
Last Name:BUSH
Suffix:
Gender:F
Credentials:CDCA170942
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1791 ALUM CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-1757
Mailing Address - Country:US
Mailing Address - Phone:614-445-8131
Mailing Address - Fax:
Practice Address - Street 1:1430 S HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-1045
Practice Address - Country:US
Practice Address - Phone:614-445-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.170942101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0378003Medicaid
OH170942OtherOHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD