MEDICARE: SHANE BUSH PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	012998-2	NY
2	103G00000X	Clinical Neuropsychologist	012998	NY
3	103TR0400X	Rehabilitation Psychologist	012998	NY

General Provider Information

NPI Number	:	1003868514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE BUSH PH.D.

Provider Business Mailing Address
First Line	:	290 HAWKINS AVE
Second Line	:	SUITE B
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-9600
Country	:	US
Telephone Number	:	631-334-7884
Fax Number	:	631-980-3715

Provider Business Practice Location Address
First Line	:	290 HAWKINS AVE
Second Line	:	SUITE B
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-9600
Country	:	US
Telephone Number	:	631-334-7884
Fax Number	:	631-980-3715

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	07/18/2007

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Directions to “ SHANE BUSH PH.D.” Practice Location

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