Healthcare Provider Details

I. General information

NPI: 1740997477
Provider Name (Legal Business Name): RUSH PEDIATRIC NEUROPSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 PLYMOUTH AVE NE
GRAND RAPIDS MI
49505-6028
US

IV. Provider business mailing address

412 PLYMOUTH AVE NE
GRAND RAPIDS MI
49505-6028
US

V. Phone/Fax

Practice location:
  • Phone: 616-780-0590
  • Fax: 616-984-4559
Mailing address:
  • Phone: 616-780-0590
  • Fax: 616-984-4559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: SHANA J RUSH
Title or Position: OWNER
Credential: PHD
Phone: 616-780-0590