Provider Demographics
NPI:1932607546
Name:BUSH, PERNELL MJ (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PERNELL
Middle Name:MJ
Last Name:BUSH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:PERNELL
Other - Middle Name:MICHEALJEREMY
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:819 E 1ST ST STE 4
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1467
Mailing Address - Country:US
Mailing Address - Phone:407-906-0139
Mailing Address - Fax:407-542-5935
Practice Address - Street 1:819 E 1ST ST STE 4
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1467
Practice Address - Country:US
Practice Address - Phone:407-906-0139
Practice Address - Fax:407-542-5935
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW181091041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLWMRMFOtherBCBS
FL5845848OtherCIGNA
FL6157870OtherAETNA
FL601535783OtherMEGELLAN
FLOH308OtherMEDICARE
FL1099907OtherOPTUM