Healthcare Provider Details

I. General information

NPI: 1245205053
Provider Name (Legal Business Name): LYNN RUTH GRUSH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 08/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 CENTRE ST STE 204
NEWTON CENTER MA
02459
US

IV. Provider business mailing address

1340 CENTRE ST STE 204
NEWTON CENTRE MA
02459-2453
US

V. Phone/Fax

Practice location:
  • Phone: 617-795-7130
  • Fax: 617-795-0953
Mailing address:
  • Phone: 617-795-7130
  • Fax: 617-795-0953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number76631
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number76631
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: