Provider Demographics
NPI:1619486081
Name:BUSH, SELENA (LCSW)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4673 STATE HIGHWAY 58
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-3202
Mailing Address - Country:US
Mailing Address - Phone:863-888-6464
Mailing Address - Fax:386-888-6465
Practice Address - Street 1:4673 STATE HIGHWAY 58
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-3202
Practice Address - Country:US
Practice Address - Phone:386-888-6464
Practice Address - Fax:386-888-6465
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085840-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05620695Medicaid