Provider Demographics
NPI:1801622329
Name:BUSH, DESMOND DEWAYNE
Entity type:Individual
Prefix:
First Name:DESMOND
Middle Name:DEWAYNE
Last Name:BUSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 MURFREESBORO PIKE APT 130
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-3941
Mailing Address - Country:US
Mailing Address - Phone:615-887-9108
Mailing Address - Fax:
Practice Address - Street 1:2760 MURFREESBORO PIKE APT 130
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3941
Practice Address - Country:US
Practice Address - Phone:615-887-9108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician