Provider Demographics
NPI:1710082656
Name:BUSH, FREDERICK JR (LMSW)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:
Last Name:BUSH
Suffix:JR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:NY
Mailing Address - Zip Code:13080-9736
Mailing Address - Country:US
Mailing Address - Phone:315-425-2941
Mailing Address - Fax:
Practice Address - Street 1:800 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2716
Practice Address - Country:US
Practice Address - Phone:315-425-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0668691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical