Provider Demographics
NPI:1285171108
Name:BUSHEK, SUSAN (MPS, LPCC, LADC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BUSHEK
Suffix:
Gender:F
Credentials:MPS, LPCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11005 OAK GROVE CIRCLE
Mailing Address - Street 2:UNIT B
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129
Mailing Address - Country:US
Mailing Address - Phone:763-350-7053
Mailing Address - Fax:763-789-4798
Practice Address - Street 1:1650 CARROLL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5227
Practice Address - Country:US
Practice Address - Phone:763-789-4895
Practice Address - Fax:763-789-4798
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303614101YA0400X
MN1197101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional