Provider Demographics
NPI:1285975425
Name:BUSHMAN, MARNIE MARIE
Entity type:Individual
Prefix:MRS
First Name:MARNIE
Middle Name:MARIE
Last Name:BUSHMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MARNIE
Other - Middle Name:MARIE
Other - Last Name:MUNK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:219 W 700 N
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-1441
Mailing Address - Country:US
Mailing Address - Phone:435-730-3669
Mailing Address - Fax:
Practice Address - Street 1:219 W 700 N
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302
Practice Address - Country:US
Practice Address - Phone:435-730-3669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2712788-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty