Provider Demographics
NPI:1750611042
Name:TAYLOR-BUSH, TONYA RENEE (MA, CSAC, QMHP)
Entity type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:RENEE
Last Name:TAYLOR-BUSH
Suffix:
Gender:F
Credentials:MA, CSAC, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-5606
Mailing Address - Country:US
Mailing Address - Phone:757-735-9252
Mailing Address - Fax:
Practice Address - Street 1:210 N BROAD ST
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-5606
Practice Address - Country:US
Practice Address - Phone:757-923-1379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102607101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0710102607Medicaid