Healthcare Provider Details

I. General information

NPI: 1295655033
Provider Name (Legal Business Name): DOMINIQUE BUSH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BALCONES DR STE 25157
AUSTIN TX
78731-4257
US

IV. Provider business mailing address

5900 BALCONES DR STE 25157
AUSTIN TX
78731-4257
US

V. Phone/Fax

Practice location:
  • Phone: 254-467-1267
  • Fax: 866-258-5843
Mailing address:
  • Phone: 254-467-1267
  • Fax: 866-258-5843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113775
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: