Provider Demographics
NPI:1861998445
Name:BUSH, TAMMY J (LCDC111)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:J
Last Name:BUSH
Suffix:
Gender:F
Credentials:LCDC111
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 COLUMBUS RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1334
Mailing Address - Country:US
Mailing Address - Phone:740-592-6724
Mailing Address - Fax:740-592-6728
Practice Address - Street 1:507 MULBERRY HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:POMEROY
Practice Address - State:OH
Practice Address - Zip Code:45769-9573
Practice Address - Country:US
Practice Address - Phone:740-992-5277
Practice Address - Fax:740-992-7264
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121119101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)