Provider Demographics
NPI:1922026400
Name:BUSH, ILENE M (LMFT)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:M
Last Name:BUSH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-479-4433
Mailing Address - Fax:502-451-5949
Practice Address - Street 1:1951 BISHOP LN
Practice Address - Street 2:SUITE 204/206
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1930
Practice Address - Country:US
Practice Address - Phone:502-479-4433
Practice Address - Fax:502-451-5949
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0464106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYHUMANAOther000019922
KY278263OtherUNITED BEHAVIORAL HEALTH
KY7100281800Medicaid