Healthcare Provider Details

I. General information

NPI: 1215852819
Provider Name (Legal Business Name): BRYON KEITH BUSH SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 S MARY ETTA ST
DERBY KS
67037-2225
US

IV. Provider business mailing address

224 S MARY ETTA ST
DERBY KS
67037-2225
US

V. Phone/Fax

Practice location:
  • Phone: 316-706-8027
  • Fax:
Mailing address:
  • Phone: 316-706-8027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number323
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: