Provider Demographics
NPI:1205425253
Name:BUSH, DIANE MARIE (CADC, LPCC, NCC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:BUSH
Suffix:
Gender:F
Credentials:CADC, LPCC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5704 FRUITWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40272-5018
Mailing Address - Country:US
Mailing Address - Phone:502-510-3947
Mailing Address - Fax:
Practice Address - Street 1:105 DAVENTRY LN STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3874
Practice Address - Country:US
Practice Address - Phone:502-510-3947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY164184101YA0400X
KY264319101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100818890Medicaid