Provider Demographics
NPI:1467093054
Name:BUSH COUNSELING SERVICE LCSW PLLC
Entity Type:Organization
Organization Name:BUSH COUNSELING SERVICE LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:386-888-6464
Mailing Address - Street 1:4673 STATE HIGHWAY 58
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-3202
Mailing Address - Country:US
Mailing Address - Phone:386-888-6464
Mailing Address - Fax:386-888-6465
Practice Address - Street 1:4673 STATE HIGHWAY 58
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-3202
Practice Address - Country:US
Practice Address - Phone:386-888-6464
Practice Address - Fax:386-888-6465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-04
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05620695Medicaid