Basic Information
| Provider Information | |||||||||
| NPI: | 1063183135 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSH | ||||||||
| FirstName: | YAISHA | ||||||||
| MiddleName: | DAMEKA | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3409 LAKE PARK CT | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954035726 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 725 GROVE ST | ||||||||
| Address2: | |||||||||
| City: | HEALDSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954484756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074334877 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2021 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 5025 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.