Provider Demographics
NPI:1912777376
Name:BUSH, RENAE MARIE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:RENAE
Middle Name:MARIE
Last Name:BUSH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 TERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08882-2531
Mailing Address - Country:US
Mailing Address - Phone:732-735-1425
Mailing Address - Fax:
Practice Address - Street 1:13 CLYDE RD STE 103
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5037
Practice Address - Country:US
Practice Address - Phone:848-999-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00607000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional