Provider Demographics
NPI:1629248406
Name:BUSHUR, KELLY A (CP PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:BUSHUR
Suffix:
Gender:F
Credentials:CP PHD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:RHODES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CP PHD
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:618-985-6860
Practice Address - Street 1:400 S LEWIS LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3547
Practice Address - Country:US
Practice Address - Phone:618-519-9900
Practice Address - Fax:618-529-1384
Is Sole Proprietor?:No
Enumeration Date:2008-03-07
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005772103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854006Medicaid
IL370966854015Medicaid
IL370966854002Medicaid
IL370966854024Medicaid
IL370966854005Medicaid
IL640701OtherMEDICARE GROUP ID
IL141848Medicare Oscar/Certification
IL640701OtherMEDICARE GROUP ID
IL141840Medicare Oscar/Certification
IL370966854005Medicaid
IL141112Medicare Oscar/Certification