Provider Demographics
NPI:1689747941
Name:BUSH, MELISSA V (PHD)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:V
Last Name:BUSH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 PRESTON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-1632
Mailing Address - Country:US
Mailing Address - Phone:803-799-8466
Mailing Address - Fax:803-252-7658
Practice Address - Street 1:1620 LADY ST
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3404
Practice Address - Country:US
Practice Address - Phone:803-799-8466
Practice Address - Fax:803-252-7658
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC139101YP2500X
SC140106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist