{
"Npi": {
"NPI": "1316133705",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "BUSH",
"FirstName": "THADDEAUS",
"MiddleName": "WAYNE",
"NamePrefix": "MR.",
"NameSuffix": "SR.",
"Credential": "CATC",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "BUSH",
"OtherFirstName": "THADDAEUS",
"OtherMiddleName": "WAYNE",
"OtherNamePrefix": "MR.",
"OtherNameSuffix": null,
"OtherCredential": "CATC",
"OtherLastNameTypeCode": "5",
"FirstLineMailingAddress": "1212 N. CALIFORNIA ST.",
"SecondLineMailingAddress": "SAN JOAQUIN COUNTY BEHAVIORAL HEALTH",
"MailingAddressCityName": "STOCKTON",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "95202",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "209-468-6857",
"MailingAddressFaxNumber": "209-468-6739",
"FirstLinePracticeLocationAddress": "500 W. HOSPITAL RD.",
"SecondLinePracticeLocationAddress": "RECOVERY HOUSE",
"PracticeLocationAddressCityName": "FRENCH CAMP",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "95231",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "209-468-6857",
"PracticeLocationAddressFaxNumber": "209-468-6739",
"EnumerationDate": "09/19/2007",
"LastUpdateDate": "10/23/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "101Y00000X",
"TaxonomyName": "Counselor",
"LicenseNumber": "B0411260821",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}