Healthcare Provider Details

I. General information

NPI: 1720771900
Provider Name (Legal Business Name): MIKAYLA NICOLE RUSH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E BELTLINE AVE NE
GRAND RAPIDS MI
49506-1214
US

IV. Provider business mailing address

2015 ORLOV DR
HUDSONVILLE MI
49426-7514
US

V. Phone/Fax

Practice location:
  • Phone: 616-805-3660
  • Fax: 616-805-3631
Mailing address:
  • Phone: 616-560-4356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401225704
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401225704
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: