Provider Demographics
NPI:1851867956
Name:BUSH, RUSSELL (SLP)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 W 75TH ST STE 121
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2241
Mailing Address - Country:US
Mailing Address - Phone:913-362-7518
Mailing Address - Fax:913-362-7302
Practice Address - Street 1:10000 W 75TH ST STE 121
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-2241
Practice Address - Country:US
Practice Address - Phone:913-362-7518
Practice Address - Fax:913-362-7302
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008019338235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty