Healthcare Provider Details

I. General information

NPI: 1316133705
Provider Name (Legal Business Name): THADDEAUS WAYNE BUSH SR. CATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: THADDAEUS WAYNE BUSH CATC

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W. HOSPITAL RD. RECOVERY HOUSE
FRENCH CAMP CA
95231
US

IV. Provider business mailing address

1212 N. CALIFORNIA ST. SAN JOAQUIN COUNTY BEHAVIORAL HEALTH
STOCKTON CA
95202
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-6857
  • Fax: 209-468-6739
Mailing address:
  • Phone: 209-468-6857
  • Fax: 209-468-6739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberB0411260821
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: