Provider Demographics
NPI:1174640668
Name:BUSH, DANA G (PHD)
Entity type:Individual
Prefix:DR
First Name:DANA
Middle Name:G
Last Name:BUSH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 W 56TH ST STE 1804
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3878
Mailing Address - Country:US
Mailing Address - Phone:212-851-8100
Mailing Address - Fax:888-977-2547
Practice Address - Street 1:290 HAWKINS AVE
Practice Address - Street 2:STE. B
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-9600
Practice Address - Country:US
Practice Address - Phone:631-431-1581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013045103T00000X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent