Basic Information
| Provider Information | |||||||||
| NPI: | 1811228075 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSHY | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 25TH ST S | ||||||||
| Address2: | PO BOX 9859 | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581032311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 7014514893 | ||||||||
| Practice Location | |||||||||
| Address1: | 224 4TH ST NW STE 5 | ||||||||
| Address2: | |||||||||
| City: | DEVILS LAKE | ||||||||
| State: | ND | ||||||||
| PostalCode: | 583012960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016626776 | ||||||||
| FaxNumber: | 7016626889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2010 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 630-3-15-09A | ND | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 630-3-15-09-316 | ND | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.