Provider Demographics
NPI:1275372716
Name:BUSHMAN, TRISTAN ROBERT (LCSW)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:ROBERT
Last Name:BUSHMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17374 BIGLEAF MAPLE BLVD APT 933
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-5061
Mailing Address - Country:US
Mailing Address - Phone:317-213-3570
Mailing Address - Fax:
Practice Address - Street 1:322 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4622
Practice Address - Country:US
Practice Address - Phone:765-776-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34011137A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical