Healthcare Provider Details

I. General information

NPI: 1003868514
Provider Name (Legal Business Name): SHANE BUSH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 HAWKINS AVE SUITE B
LAKE RONKONKOMA NY
11779-9600
US

IV. Provider business mailing address

290 HAWKINS AVE SUITE B
LAKE RONKONKOMA NY
11779-9600
US

V. Phone/Fax

Practice location:
  • Phone: 631-334-7884
  • Fax: 631-980-3715
Mailing address:
  • Phone: 631-334-7884
  • Fax: 631-980-3715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number012998-2
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number012998
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number012998
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: