Provider Demographics
NPI:1306329461
Name:BUSHEY, ELIZABETH M
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:BUSHEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-453-6716
Practice Address - Street 1:601 CLEVELAND AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-1836
Practice Address - Country:US
Practice Address - Phone:330-455-0374
Practice Address - Fax:330-453-6716
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOCPS.1159405300000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0459051Medicaid