Basic Information
| Provider Information | |||||||||
| NPI: | 1609145523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSH | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILL | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | DEPT 781625 | ||||||||
| Address2: | PO BOX 78000 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558004 | ||||||||
| FaxNumber: | 6143552220 | ||||||||
| Practice Location | |||||||||
| Address1: | 495 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558007 | ||||||||
| FaxNumber: | 6143558620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2011 | ||||||||
| LastUpdateDate: | 06/01/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | E1100580-SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2846675 | 05 | OH | MEDICAID |