Provider Demographics
NPI:1952633661
Name:BUSH, CHARLES DANIEL JR (MFT INTERN)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DANIEL
Last Name:BUSH
Suffix:JR
Gender:M
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:460 E CARSON PLAZA DR
Mailing Address - Street 2:SUITE 122
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3228
Mailing Address - Country:US
Mailing Address - Phone:310-523-9500
Mailing Address - Fax:310-225-2725
Practice Address - Street 1:460 E CARSON PLAZA DR
Practice Address - Street 2:SUITE 122
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3278
Practice Address - Country:US
Practice Address - Phone:310-523-9500
Practice Address - Fax:310-225-2725
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70425101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health