Provider Demographics
NPI:1396116562
Name:BUSH, THEODORE IV
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:BUSH
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 N BROAD ST STE A
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-5507
Mailing Address - Country:US
Mailing Address - Phone:504-577-1154
Mailing Address - Fax:
Practice Address - Street 1:209 N BROAD ST STE A
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119
Practice Address - Country:US
Practice Address - Phone:504-577-1154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X101YP1600X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600723292Medicaid