Provider Demographics
NPI:1497634687
Name:GISSENTANNER-BUSH, ERICA
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:GISSENTANNER-BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 541381
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-1381
Mailing Address - Country:US
Mailing Address - Phone:789-890-3555
Mailing Address - Fax:
Practice Address - Street 1:14145 NW 22ND PL
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-3720
Practice Address - Country:US
Practice Address - Phone:786-890-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-01
Last Update Date:2025-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH26053101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health