Healthcare Provider Details

I. General information

NPI: 1245603703
Provider Name (Legal Business Name): NICKOLAS BUSHON M.A., TLLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 INDUSTRIAL DR
OWOSSO MI
48867-9775
US

IV. Provider business mailing address

PO BOX 428
OWOSSO MI
48867-0428
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-6791
  • Fax: 989-725-5061
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301016436
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: