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General NPI Number Information
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NPI Number | 1316133705
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Entity Type | Individual
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Provider Name | THADDEAUS WAYNE BUSH SR. CATC
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Gender | Male
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Dates
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Enumeration Date | 09/19/2007
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Last Update Date | 10/23/2017
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Provider Practice Location Address
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Address Line | 500 W. HOSPITAL RD. RECOVERY HOUSE
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City | FRENCH CAMP
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State | CA
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Zip | 95231
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Country | US
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Telephone | 209-468-6857
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Fax | 209-468-6739
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Provider Business Mailing Address
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Address Line | 1212 N. CALIFORNIA ST. SAN JOAQUIN COUNTY BEHAVIORAL HEALTH
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City | STOCKTON
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State | CA
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Zip | 95202
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Country | US
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Telephone | 209-468-6857
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Fax | 209-468-6739
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | B0411260821
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License Number State | CA
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