Provider Demographics
NPI:1194185215
Name:BUSH, TIFFANY (LCAS)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 SUNNY ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NC
Mailing Address - Zip Code:28752-6411
Mailing Address - Country:US
Mailing Address - Phone:828-803-2985
Mailing Address - Fax:828-287-7946
Practice Address - Street 1:356 CHARLOTTE RD
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-2916
Practice Address - Country:US
Practice Address - Phone:828-287-7945
Practice Address - Fax:828-287-7946
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22537101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)