Basic Information
| Provider Information | |||||||||
| NPI: | 1922278324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSH | ||||||||
| FirstName: | MADELINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUSH | ||||||||
| OtherFirstName: | MADELINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 178-10 WEXFORD TERRACE | ||||||||
| Address2: | ADVANCED CENTER FOR PSYCHOTHERAPY | ||||||||
| City: | JAMAICA ESTATES | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114323003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186581123 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 178-10 WEXFORD TERRACE | ||||||||
| Address2: | ADVANCED CENTER FOR PSYCHOTHERAPY | ||||||||
| City: | JAMAICA ESTATES | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114323003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186581123 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2008 | ||||||||
| LastUpdateDate: | 06/15/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R022349 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.