Provider Demographics
NPI:1043708043
Name:BUSH, AUTUMN QUIANA (LCSW)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:QUIANA
Last Name:BUSH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 POPHAM AVE APT 1J
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-7233
Mailing Address - Country:US
Mailing Address - Phone:518-879-2434
Mailing Address - Fax:
Practice Address - Street 1:235 MAIN ST STE 520
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-2421
Practice Address - Country:US
Practice Address - Phone:914-533-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103001104100000X
NY0967251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker