Individual
KELLY A BUSHUR
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CP PH.D
Contact information
Practice address
400 S LEWIS LN, CARBONDALE, IL 62901-3547
(618) 519-9900
(618) 529-1384
Mailing address
PO BOX 577, CARTERVILLE, IL 62918-0577
(618) 985-8221
(618) 985-6860
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
071005772
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
370966854002
—
IL
05
—
370966854005
—
IL
05
—
370966854006
—
IL
05
—
370966854015
—
IL
05
—
370966854024
—
IL
01
—
640701
MEDICARE GROUP ID
IL
Enumeration date
03/07/2008
Last updated
10/23/2014
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