=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043708043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUTUMN QUIANA BUSH LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2018
-----------------------------------------------------
Last Update Date | 12/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 MAIN ST STE 520
-----------------------------------------------------
City | WHITE PLAINS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10601-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-533-4950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1480 POPHAM AVE APT 1J
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10453-7233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-879-2434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 103001
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 096725
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------