Provider Demographics
NPI:1821856782
Name:BUSHMAN, CHANNING TRUUS
Entity Type:Individual
Prefix:
First Name:CHANNING
Middle Name:TRUUS
Last Name:BUSHMAN
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 1:9231 ELK GROVE FLORIN RD APT 147
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1664
Mailing Address - Country:US
Mailing Address - Phone:408-710-4051
Mailing Address - Fax:
Practice Address - Street 1:9231 ELK GROVE FLORIN RD APT 147
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1664
Practice Address - Country:US
Practice Address - Phone:408-710-4051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15960101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health