Healthcare Provider Details

I. General information

NPI: 1811228075
Provider Name (Legal Business Name): CHRISTINE J BUSHY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 4TH ST NW STE 5
DEVILS LAKE ND
58301-2960
US

IV. Provider business mailing address

1201 25TH ST S PO BOX 9859
FARGO ND
58103-2311
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-6776
  • Fax: 701-662-6889
Mailing address:
  • Phone: 701-451-4900
  • Fax: 701-451-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number630-3-15-09A
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number630-3-15-09-316
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: