Provider Demographics
NPI:1295512002
Name:BUSH, LIISA MARIE (SAC-IT)
Entity type:Individual
Prefix:
First Name:LIISA
Middle Name:MARIE
Last Name:BUSH
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:LIISA
Other - Middle Name:MARIE
Other - Last Name:BUSHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1416 W WEILAND LN
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-5810
Mailing Address - Country:US
Mailing Address - Phone:920-716-7619
Mailing Address - Fax:
Practice Address - Street 1:505 S WASHBURN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7949
Practice Address - Country:US
Practice Address - Phone:920-232-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20339-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)