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General NPI Number Information
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NPI Number | 1356926372
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Entity Type | Organization
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Legal Business Name | EVERGLADE PSYCHOTHERAPY GROUP LLC
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Dates
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Enumeration Date | 03/11/2021
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Last Update Date | 03/11/2021
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Provider Practice Location Address
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Address Line | 73 CAVALIER BLVD STE 321
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City | FLORENCE
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State | KY
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Zip | 41042-5185
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Country | US
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Telephone | 513-341-5241
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Fax |
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Provider Business Mailing Address
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Address Line | 10228 HEMPSTEADE DR
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City | UNION
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State | KY
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Zip | 41091-9484
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Country | US
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Telephone | 513-341-5241
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DANIEL J BUSH
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Credential | PHD, THM, MDIV, MA
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Telephone | 513-341-5241
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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