Provider Demographics
NPI:1942551585
Name:BUSH, MARSHALL (PHD)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1054
Mailing Address - Country:US
Mailing Address - Phone:415-561-6775
Mailing Address - Fax:
Practice Address - Street 1:9 FUNSTON AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94129-1110
Practice Address - Country:US
Practice Address - Phone:415-561-6775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-22
Last Update Date:2012-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY3349103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical