Healthcare Provider Details

I. General information

NPI: 1013128446
Provider Name (Legal Business Name): JOSIE ELLEN BUSH M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S. STREETCAR WAY
LOST CREEK WV
26385-0490
US

IV. Provider business mailing address

PO BOX 490 107 S. STREETCAR WAY
LOST CREEK WV
26385-0490
US

V. Phone/Fax

Practice location:
  • Phone: 304-745-5065
  • Fax: 304-745-5067
Mailing address:
  • Phone: 304-745-5065
  • Fax: 304-745-5067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1729
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: