Healthcare Provider Details

I. General information

NPI: 1649321191
Provider Name (Legal Business Name): KELLY M BUSH PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 S BROADWAY STE 300 DEPT OF MENTAL HEALTH
WALNUT CREEK CA
94596-5229
US

IV. Provider business mailing address

710 S BROADWAY STE 300 DEPT OF MENTAL HEALTH
WALNUT CREEK CA
94596-5229
US

V. Phone/Fax

Practice location:
  • Phone: 925-295-4145
  • Fax:
Mailing address:
  • Phone: 925-295-4145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number19826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: