Healthcare Provider Details

I. General information

NPI: 1114222320
Provider Name (Legal Business Name): ILENE NAOMI RUSK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2523 BROADWAY SUITE 200
BOULDER CO
80304-4240
US

IV. Provider business mailing address

2523 BROADWAY SUITE 200
BOULDER CO
80304-4240
US

V. Phone/Fax

Practice location:
  • Phone: 303-938-9244
  • Fax: 303-413-1308
Mailing address:
  • Phone: 303-938-9244
  • Fax: 303-413-1308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number7079
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: