Provider Demographics
NPI:1639311418
Name:BUSH, MARY BETH
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12350 SW 5TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2819
Mailing Address - Country:US
Mailing Address - Phone:503-627-9194
Mailing Address - Fax:503-627-9095
Practice Address - Street 1:12350 SW 5TH ST STE 110
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2819
Practice Address - Country:US
Practice Address - Phone:503-627-9194
Practice Address - Fax:503-627-9095
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health