Healthcare Provider Details

I. General information

NPI: 1548393754
Provider Name (Legal Business Name): VICKIE LYNN BUSH LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 6TH STREET SE WOODLAND CENTERS
WILLMAR MN
56201-4675
US

IV. Provider business mailing address

919 NO 17TH STREET
MONTEVIDEO MN
55265
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-9148
  • Fax: 320-231-9140
Mailing address:
  • Phone: 320-235-4613
  • Fax: 320-231-9140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number300202
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8024
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: