Provider Demographics
NPI:1518110733
Name:BUSH, DARRELL CRAIG (MSW)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:CRAIG
Last Name:BUSH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 997
Mailing Address - Street 2:24 CHERRY ST.
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790
Mailing Address - Country:US
Mailing Address - Phone:607-723-8313
Mailing Address - Fax:607-723-6173
Practice Address - Street 1:24 CHERRY ST # PO
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2615
Practice Address - Country:US
Practice Address - Phone:607-723-8313
Practice Address - Fax:607-723-6173
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator