Healthcare Provider Details

I. General information

NPI: 1497634687
Provider Name (Legal Business Name): ERICA GISSENTANNER-BUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2025
Last Update Date: 09/01/2025
Certification Date: 08/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14145 NW 22ND PL
OPA LOCKA FL
33054-3720
US

IV. Provider business mailing address

PO BOX 541381
OPA LOCKA FL
33054-1381
US

V. Phone/Fax

Practice location:
  • Phone: 786-890-3555
  • Fax:
Mailing address:
  • Phone: 789-890-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH26053
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: