Provider Demographics
NPI:1538635438
Name:BUSH, LAURI MICHELE
Entity type:Individual
Prefix:
First Name:LAURI
Middle Name:MICHELE
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURI
Other - Middle Name:MICHELE
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:737 FAWCETT AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402
Mailing Address - Country:US
Mailing Address - Phone:253-396-5800
Mailing Address - Fax:253-697-3730
Practice Address - Street 1:737 FAWCETT AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402
Practice Address - Country:US
Practice Address - Phone:253-396-5800
Practice Address - Fax:253-697-3730
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60770025175T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist