Provider Demographics
NPI:1205869005
Name:BUSHELL, LORI (LCPC)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BUSHELL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W PIONEER PKWY STE 20
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-5805
Mailing Address - Country:US
Mailing Address - Phone:309-231-6180
Mailing Address - Fax:309-213-9485
Practice Address - Street 1:2001 W WILLOW KNOLLS DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1290
Practice Address - Country:US
Practice Address - Phone:309-263-5565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004972101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health