Provider Demographics
NPI:1801166400
Name:BUSH, MANDY KAY (MSED, ATC/LAT)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:KAY
Last Name:BUSH
Suffix:
Gender:F
Credentials:MSED, ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17764 SUNDIAL CT
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46062-7640
Mailing Address - Country:US
Mailing Address - Phone:317-379-3191
Mailing Address - Fax:
Practice Address - Street 1:1100 E 5TH ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-3462
Practice Address - Country:US
Practice Address - Phone:765-641-4493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001016A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer