Provider Demographics
NPI:1477227502
Name:BUSH, KEIARA
Entity Type:Individual
Prefix:
First Name:KEIARA
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 HICKORY MNR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3475
Mailing Address - Country:US
Mailing Address - Phone:618-207-0191
Mailing Address - Fax:
Practice Address - Street 1:101 S BELT W
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-2503
Practice Address - Country:US
Practice Address - Phone:618-277-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056014289225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist