Basic Information
| Provider Information | |||||||||
| NPI: | 1225248834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSH | ||||||||
| FirstName: | DURRICK | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 139C E JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716554933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012622544 | ||||||||
| FaxNumber: | 8702248110 | ||||||||
| Practice Location | |||||||||
| Address1: | 139C E JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716554933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012622544 | ||||||||
| FaxNumber: | 8702248110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | M0809010 | AR | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.