Provider Demographics
NPI:1144659103
Name:BUSCH, KATHRYN AMANDA (LMFT)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:AMANDA
Last Name:BUSCH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MISS
Other - First Name:KATHRYN
Other - Middle Name:AMANDA
Other - Last Name:GEDDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:24 PAMELA LN
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-3155
Mailing Address - Country:US
Mailing Address - Phone:631-946-6818
Mailing Address - Fax:
Practice Address - Street 1:20 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1139
Practice Address - Country:US
Practice Address - Phone:631-258-5587
Practice Address - Fax:631-363-0027
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-10
Last Update Date:2014-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001044106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist