MEDICARE: AVERY FONTAINE BUSH LPC

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	101YM0800X	Mental Health Counselor	85644	TX

General Provider Information

NPI Number	:	1881521029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AVERY FONTAINE BUSH LPC

Provider Business Mailing Address
First Line	:	4925 GREENVILLE AVE STE 680
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75206-4087
Country	:	US
Telephone Number	:	214-542-0129
Fax Number	:

Provider Business Practice Location Address
First Line	:	4925 GREENVILLE AVE STE 680
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75206-4087
Country	:	US
Telephone Number	:	214-542-0129
Fax Number	:

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

Provider Enumeration Date	:	05/04/2026
Last Update Date	:	05/04/2026

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Directions to “ AVERY FONTAINE BUSH LPC” Practice Location

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