Basic Information
| Provider Information | |||||||||
| NPI: | 1629248406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSHUR | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CP PH.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RHODES | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CP PH.D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 577 | ||||||||
| Address2: | |||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629180577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189858221 | ||||||||
| FaxNumber: | 6189856860 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S LEWIS LN | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185199900 | ||||||||
| FaxNumber: | 6185291384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2008 | ||||||||
| LastUpdateDate: | 10/23/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 071005772 | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 370966854006 | 05 | IL | MEDICAID | 370966854015 | 05 | IL | MEDICAID | 370966854002 | 05 | IL | MEDICAID | 370966854024 | 05 | IL | MEDICAID | 370966854005 | 05 | IL | MEDICAID | 640701 | 01 | IL | MEDICARE GROUP ID | OTHER |