Provider Demographics
NPI:1437729563
Name:BUSH, EVAN CARSON (LAC)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:CARSON
Last Name:BUSH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21069 E PROSPECTOR PL
Mailing Address - Street 2:
Mailing Address - City:RED ROCK
Mailing Address - State:AZ
Mailing Address - Zip Code:85145-5019
Mailing Address - Country:US
Mailing Address - Phone:801-520-5388
Mailing Address - Fax:
Practice Address - Street 1:3535 S RICHEY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-5432
Practice Address - Country:US
Practice Address - Phone:520-886-1136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-19564101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor