Provider Demographics
NPI:1912991852
Name:BUSH, MARY T (PHD, PSYNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:BUSH
Suffix:
Gender:F
Credentials:PHD, PSYNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 N 47TH AVE
Mailing Address - Street 2:STE 6
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-4172
Mailing Address - Country:US
Mailing Address - Phone:602-957-2710
Mailing Address - Fax:623-934-5895
Practice Address - Street 1:6630 N 47TH AVE
Practice Address - Street 2:STE 6
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-4172
Practice Address - Country:US
Practice Address - Phone:602-957-2710
Practice Address - Fax:623-934-5895
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2008-01-09
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
AZ1909103T00000X
AZAP2219163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR70525Medicare UPIN
AZZPHD1909Medicare PIN