Provider Demographics
NPI:1801566484
Name:HAWORTH-BUSH, DEBRA MAE (CADC,CPRC,CPSS,CFSP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:MAE
Last Name:HAWORTH-BUSH
Suffix:
Gender:F
Credentials:CADC,CPRC,CPSS,CFSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2160
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-0908
Mailing Address - Country:US
Mailing Address - Phone:208-263-7101
Mailing Address - Fax:
Practice Address - Street 1:30410 HIGHWAY 200 STE 200
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-9601
Practice Address - Country:US
Practice Address - Phone:208-263-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID12953101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)