Provider Demographics
NPI:1730756917
Name:BUSH, CAROLINE BRINSON (PTA)
Entity type:Individual
Prefix:MISS
First Name:CAROLINE
Middle Name:BRINSON
Last Name:BUSH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6243 S WAYLAND WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5711
Mailing Address - Country:US
Mailing Address - Phone:901-786-2761
Mailing Address - Fax:
Practice Address - Street 1:960 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3600
Practice Address - Country:US
Practice Address - Phone:208-433-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-7147225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPTA-7147Medicaid