Provider Demographics
NPI:1467122796
Name:BUSH, MADELINE RAE (MED)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:RAE
Last Name:BUSH
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 STATION RD APT 1
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-2326
Mailing Address - Country:US
Mailing Address - Phone:570-220-6342
Mailing Address - Fax:
Practice Address - Street 1:9 STATION RD APT 1
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-2326
Practice Address - Country:US
Practice Address - Phone:570-220-6342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health