Healthcare Provider Details

I. General information

NPI: 1063662906
Provider Name (Legal Business Name): DONALD P. RUSH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 10/26/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 RANDOLPH RD SUITE 800
CHARLOTTE NC
28207-1122
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-1246
  • Fax: 704-384-6072
Mailing address:
  • Phone: 704-384-1246
  • Fax: 704-384-6072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC005000
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: