Healthcare Provider Details

I. General information

NPI: 1235219726
Provider Name (Legal Business Name): MARY DENISE BUSCH PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 SE 8TH AVE
HILLSBORO OR
97123-4218
US

IV. Provider business mailing address

PO BOX 6149
ALOHA OR
97007-0149
US

V. Phone/Fax

Practice location:
  • Phone: 503-601-7400
  • Fax: 503-601-7311
Mailing address:
  • Phone: 503-352-8642
  • Fax: 503-352-8658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number097006687N6PMHNP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201050124NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: