Provider Demographics
NPI:1659955193
Name:BUSH, MATTHEW A
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
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 1:119 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:MC ARTHUR
Mailing Address - State:OH
Mailing Address - Zip Code:45651-1071
Mailing Address - Country:US
Mailing Address - Phone:740-818-9651
Mailing Address - Fax:
Practice Address - Street 1:17273 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-9718
Practice Address - Country:US
Practice Address - Phone:740-773-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2005591104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker