MEDICARE: MIA BUSH, LPC-S, LADC/MH, PLLC

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	251S00000X	Community/Behavioral Health Agency	5196	OK

General Provider Information

NPI Number	:	1427408558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIA BUSH, LPC-S, LADC/MH, PLLC

Provider Business Mailing Address
First Line	:	5009 N PENNSYLVANIA AVE
Second Line	:	SUITE 102
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-8887
Country	:	US
Telephone Number	:	405-446-8338
Fax Number	:

Provider Business Practice Location Address
First Line	:	5009 N PENNSYLVANIA AVE
Second Line	:	SUITE 102
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-8887
Country	:	US
Telephone Number	:	405-446-8338
Fax Number	:

Authorized Official
Title or Position	:	OWNER, LPC-S, LADC/MH
Name	:	MIA N BUSH
Credential	:
Telephone Number	:	405-446-8338

Provider Enumeration Date	:	06/20/2016
Last Update Date	:	06/20/2016

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