Provider Demographics
NPI:1649321191
Name:BUSH, KELLY M (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:BUSH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 S BROADWAY STE 300
Mailing Address - Street 2:DEPT OF MENTAL HEALTH
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5229
Mailing Address - Country:US
Mailing Address - Phone:925-295-4145
Mailing Address - Fax:
Practice Address - Street 1:710 S BROADWAY STE 300
Practice Address - Street 2:DEPT OF MENTAL HEALTH
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5229
Practice Address - Country:US
Practice Address - Phone:925-295-4145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19826103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist