Provider Demographics
NPI:1104950138
Name:BUSH, GORDON A (PH D)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:A
Last Name:BUSH
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14023 SOUTHWEST FWY
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3550
Mailing Address - Country:US
Mailing Address - Phone:281-325-4100
Mailing Address - Fax:281-325-4239
Practice Address - Street 1:14023 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3550
Practice Address - Country:US
Practice Address - Phone:281-325-4100
Practice Address - Fax:281-325-4239
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23760103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA071956OtherVALUE OPTIONS - MHC #
TX00F31CMedicare ID - Type UnspecifiedMEDICARE NUMBER