Provider Demographics
NPI:1891326690
Name:BUSH, GLADYS T (HEALTH COACH CCMA)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:T
Last Name:BUSH
Suffix:
Gender:F
Credentials:HEALTH COACH CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19284
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71149-0284
Mailing Address - Country:US
Mailing Address - Phone:318-773-0657
Mailing Address - Fax:
Practice Address - Street 1:9501 CHASE WAY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-4619
Practice Address - Country:US
Practice Address - Phone:318-773-0657
Practice Address - Fax:318-688-1559
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60312804405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAK5C6Y6M8OtherCCMA