Provider Demographics
NPI:1982783221
Name:BUSHMAN, KIMBERLY (PHD, LP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BUSHMAN
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14551 JUDICIAL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-4991
Mailing Address - Country:US
Mailing Address - Phone:952-898-5020
Mailing Address - Fax:952-898-5858
Practice Address - Street 1:14551 JUDICIAL RD STE 100
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-4991
Practice Address - Country:US
Practice Address - Phone:952-898-5020
Practice Address - Fax:952-898-5858
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3946103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN39Q41BUOtherBCBS GROUP
MN165935-00OtherAETNA
MN39Q42BUOtherBCBS INDIVIDUAL
MNHP24334OtherHEALTHPARTNERS
MN386981400Medicaid
MN58501420Medicaid
MN167373OtherU CARE
MN20206-02OtherPREFERREDONE BHP
MN61-77270OtherMEDICA UBH
MN61-77270OtherMEDICA UBH