Healthcare Provider Details

I. General information

NPI: 1063119915
Provider Name (Legal Business Name): ANDREW RYNE RUSH LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2023
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7625 N UNIVERSITY ST STE B1
PEORIA IL
61614-8304
US

IV. Provider business mailing address

508 NE 6TH ST
ATLANTA IL
61723-8923
US

V. Phone/Fax

Practice location:
  • Phone: 309-676-0538
  • Fax:
Mailing address:
  • Phone: 731-415-1430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150129434
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: