Provider Demographics
NPI:1972618742
Name:BUSHEY, KIM M (LADC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:BUSHEY
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GRAVELLE RD
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:VT
Mailing Address - Zip Code:05465-9630
Mailing Address - Country:US
Mailing Address - Phone:802-899-4754
Mailing Address - Fax:
Practice Address - Street 1:56 W TWIN OAKS TER
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7106
Practice Address - Country:US
Practice Address - Phone:802-847-3333
Practice Address - Fax:802-847-1424
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000033101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN0997Medicare ID - Type Unspecified
VTVN0997Medicare ID - Type Unspecified