Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 6301011728 | MI |
Y | 103T00000X | Psychologist | 6301011728 | MI |
NPI | 1003856113 |
---|---|
Provider Name | Matthew Warren Bush |
First Address | Grand Rapids, MI 49548-6927 |
Second Address | Holland, MI 49423-7725 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2006 |
Last Update Date | 08/07/2007 |