=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063624690
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBRA MOORE BUSHONG LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 06/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6363 FOREST PARK RD. 7TH FLOOR, SUITE 749
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-645-8500
-----------------------------------------------------
Fax | 214-645-3775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 845347
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75284-5347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-645-0624
-----------------------------------------------------
Fax | 214-645-0078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 59919
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------