Provider Demographics
NPI:1548393754
Name:BUSH, VICKIE LYNN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:LYNN
Last Name:BUSH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:919 NO 17TH STREET
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:55265
Mailing Address - Country:US
Mailing Address - Phone:320-235-4613
Mailing Address - Fax:320-231-9140
Practice Address - Street 1:1125 6TH STREET SE
Practice Address - Street 2:WOODLAND CENTERS
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4675
Practice Address - Country:US
Practice Address - Phone:320-231-9148
Practice Address - Fax:320-231-9140
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300202101YA0400X
MN80241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)