Provider Demographics
NPI:1801170378
Name:BUSH, PAMELA MAE (LLPC)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:MAE
Last Name:BUSH
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 W TEMPERANCE RD
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-1604
Mailing Address - Country:US
Mailing Address - Phone:313-610-3049
Mailing Address - Fax:
Practice Address - Street 1:8336 MONROE RD. SUITE 120, 154 & 206
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9378
Practice Address - Country:US
Practice Address - Phone:313-610-3049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI211322101YS0200X
MI6401012000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool