Provider Demographics
NPI:1316133705
Name:BUSH, THADDEAUS WAYNE SR (CATC)
Entity type:Individual
Prefix:MR
First Name:THADDEAUS
Middle Name:WAYNE
Last Name:BUSH
Suffix:SR
Gender:M
Credentials:CATC
Other - Prefix:MR
Other - First Name:THADDAEUS
Other - Middle Name:WAYNE
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CATC
Mailing Address - Street 1:1212 N. CALIFORNIA ST.
Mailing Address - Street 2:SAN JOAQUIN COUNTY BEHAVIORAL HEALTH
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202
Mailing Address - Country:US
Mailing Address - Phone:209-468-6857
Mailing Address - Fax:209-468-6739
Practice Address - Street 1:500 W. HOSPITAL RD.
Practice Address - Street 2:RECOVERY HOUSE
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231
Practice Address - Country:US
Practice Address - Phone:209-468-6857
Practice Address - Fax:209-468-6739
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB0411260821101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor