Provider Demographics
NPI:1740204056
Name:BUSH, ELLEN GREENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN GREENE
Middle Name:
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 1:4841 MONROE ST
Mailing Address - Street 2:100
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4385
Mailing Address - Country:US
Mailing Address - Phone:419-475-2535
Mailing Address - Fax:419-475-0881
Practice Address - Street 1:4841 MONROE ST
Practice Address - Street 2:100
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4385
Practice Address - Country:US
Practice Address - Phone:419-475-2535
Practice Address - Fax:419-475-0881
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4972103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical