Provider Demographics
NPI:1467503110
Name:BUSH, MARK ALAN (LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:BUSH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 DARBYSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9233
Mailing Address - Country:US
Mailing Address - Phone:330-270-5710
Mailing Address - Fax:
Practice Address - Street 1:150 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-1141
Practice Address - Country:US
Practice Address - Phone:330-399-6451
Practice Address - Fax:330-394-6266
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0005242101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000125439OtherANTHEM PIN #