Provider Demographics
NPI:1568703577
Name:BUSH, MIA (THERAPIST)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8704 NW 106TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-1210
Mailing Address - Country:US
Mailing Address - Phone:318-237-5066
Mailing Address - Fax:405-328-6887
Practice Address - Street 1:8704 NW 106TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-1210
Practice Address - Country:US
Practice Address - Phone:318-237-5066
Practice Address - Fax:405-328-6887
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17796101YM0800X
OK5196101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health