Provider Demographics
NPI:1336520212
Name:BUSH, MELISSA L
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:L
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 PRIVATE ROAD 30041
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:TX
Mailing Address - Zip Code:75570-5836
Mailing Address - Country:US
Mailing Address - Phone:903-314-0301
Mailing Address - Fax:903-314-5141
Practice Address - Street 1:162 PRIVATE ROAD 30041
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:TX
Practice Address - Zip Code:75570-5836
Practice Address - Country:US
Practice Address - Phone:903-314-0301
Practice Address - Fax:903-314-5141
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX802098651171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter