Healthcare Provider Details

I. General information

NPI: 1982858536
Provider Name (Legal Business Name): MISS VONA RENEE BUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15819 SCHOOLCRAFT ST
DETROIT MI
48227-1749
US

IV. Provider business mailing address

15819 SCHOOLCRAFT ST
DETROIT MI
48227-1749
US

V. Phone/Fax

Practice location:
  • Phone: 313-493-4900
  • Fax: 313-493-4904
Mailing address:
  • Phone: 313-493-4900
  • Fax: 313-493-4904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802058781
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: