Provider Demographics
NPI:1417700279
Name:BUSH, ANTAR T (LMSW)
Entity type:Individual
Prefix:MR
First Name:ANTAR
Middle Name:T
Last Name:BUSH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MARCY PL OFC
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-1467
Mailing Address - Country:US
Mailing Address - Phone:215-470-1173
Mailing Address - Fax:
Practice Address - Street 1:201 MARCY PL OFC
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-1467
Practice Address - Country:US
Practice Address - Phone:215-470-1173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123180104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty