Basic Information
| Provider Information | |||||||||
| NPI: | 1285171108 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSHEK | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | MPS, LPCC, LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11005 OAK GROVE CIRCLE | ||||||||
| Address2: | UNIT B | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633507053 | ||||||||
| FaxNumber: | 7637894798 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 CARROLL AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551045227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637894895 | ||||||||
| FaxNumber: | 7637894798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 303614 | MN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 1197 | MN | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 1197 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.