Provider Demographics
NPI:1619449634
Name:BUSH, JOSEPH
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 SMITHTOWN BYP STE 203
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-5011
Mailing Address - Country:US
Mailing Address - Phone:631-371-3825
Mailing Address - Fax:
Practice Address - Street 1:400 OAK ST STE 104
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-6554
Practice Address - Country:US
Practice Address - Phone:516-485-5975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104573101Y00000X
NY093361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor