Provider Demographics
NPI:1609145523
Name:BUSH, AMY LYNNE (PCC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNNE
Last Name:BUSH
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:GILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:DEPT 781625
Mailing Address - Street 2:PO BOX 78000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1625
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:614-355-2220
Practice Address - Street 1:495 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5349
Practice Address - Country:US
Practice Address - Phone:614-355-8007
Practice Address - Fax:614-355-8620
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE1100580-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid