Provider Demographics
NPI:1295987295
Name:BUSH, ALWYN L (OTA/L)
Entity type:Individual
Prefix:MR
First Name:ALWYN
Middle Name:L
Last Name:BUSH
Suffix:
Gender:M
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2166 MORNINGSTAR DR
Mailing Address - Street 2:
Mailing Address - City:ROAMING SHORES
Mailing Address - State:OH
Mailing Address - Zip Code:44084-9692
Mailing Address - Country:US
Mailing Address - Phone:440-563-9016
Mailing Address - Fax:
Practice Address - Street 1:2166 MORNINGSTAR DR
Practice Address - Street 2:
Practice Address - City:ROAMING SHORES
Practice Address - State:OH
Practice Address - Zip Code:44084-9692
Practice Address - Country:US
Practice Address - Phone:440-563-9016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA-1039224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant