Provider Demographics
NPI:1508189572
Name:BUSH, CANDY (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CANDY
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:CANDY
Other - Middle Name:
Other - Last Name:MULLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:11 WHITE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-8909
Mailing Address - Country:US
Mailing Address - Phone:812-254-5922
Mailing Address - Fax:
Practice Address - Street 1:801 S STATE ROAD 57
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-4373
Practice Address - Country:US
Practice Address - Phone:812-254-4516
Practice Address - Fax:812-254-4765
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002910A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant