Provider Demographics
NPI:1861687360
Name:BUSHNELL, MARY LU (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LU
Last Name:BUSHNELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:LU
Other - Last Name:WYLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:650 E INDIAN SCHOOL RD # 116B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1839
Mailing Address - Country:US
Mailing Address - Phone:602-277-5551
Mailing Address - Fax:
Practice Address - Street 1:650 E INDIAN SCHOOL RD # 116B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1839
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-09
Last Update Date:2007-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3900103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist