Provider Demographics
NPI:1831594191
Name:BUSH, GEORGE JR
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:BUSH
Suffix:JR
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 1:2530 FLAMINGO DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5433
Mailing Address - Country:US
Mailing Address - Phone:843-412-2572
Mailing Address - Fax:843-637-3184
Practice Address - Street 1:4050 BRIDGE VIEW DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7488
Practice Address - Country:US
Practice Address - Phone:843-579-4533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5032104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker