Healthcare Provider Details

I. General information

NPI: 1912991852
Provider Name (Legal Business Name): MARY T. BUSH PH.D., PSY.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date: 03/24/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

6630 N 47TH AVE STE 6
GLENDALE AZ
85301-4172
US

IV. Provider business mailing address

6630 N 47TH AVE STE 6
GLENDALE AZ
85301-4172
US

V. Phone/Fax

Practice location:
  • Phone: 602-957-2710
  • Fax: 623-934-5895
Mailing address:
  • Phone: 602-957-2710
  • Fax: 623-934-5895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1909
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberAP2219
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: