Provider Demographics
NPI:1548678592
Name:BUSH, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name: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 1:200 POPPYFIELD FARM DR
Mailing Address - Street 2:
Mailing Address - City:GOOD HOPE
Mailing Address - State:GA
Mailing Address - Zip Code:30641-2137
Mailing Address - Country:US
Mailing Address - Phone:912-245-9637
Mailing Address - Fax:
Practice Address - Street 1:200 POPPYFIELD FARM DR
Practice Address - Street 2:
Practice Address - City:GOOD HOPE
Practice Address - State:GA
Practice Address - Zip Code:30641-2137
Practice Address - Country:US
Practice Address - Phone:912-245-9637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA000953224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant