Provider Demographics
NPI:1699483867
Name:BUSHER, KELLY JUSTIN (LCSWA, PSS, QP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JUSTIN
Last Name:BUSHER
Suffix:
Gender:M
Credentials:LCSWA, PSS, QP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S CLAY ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:NC
Mailing Address - Zip Code:28098-1811
Mailing Address - Country:US
Mailing Address - Phone:704-778-2201
Mailing Address - Fax:
Practice Address - Street 1:127 S MAIN ST STE H
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-1618
Practice Address - Country:US
Practice Address - Phone:704-759-6525
Practice Address - Fax:704-601-3470
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0181141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical