MEDICARE: MIA BUSH THERAPIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	17796	NC
2	101YP2500X	Professional Counselor	5196	OK

General Provider Information

NPI Number	:	1568703577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA BUSH THERAPIST

Provider Business Mailing Address
First Line	:	8704 NW 106TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-1210
Country	:	US
Telephone Number	:	318-237-5066
Fax Number	:	405-328-6887

Provider Business Practice Location Address
First Line	:	8704 NW 106TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-1210
Country	:	US
Telephone Number	:	318-237-5066
Fax Number	:	405-328-6887

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2013
Last Update Date	:	12/26/2025

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Directions to “ MIA BUSH THERAPIST” Practice Location

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