Healthcare Provider Details

I. General information

NPI: 1699911750
Provider Name (Legal Business Name): EDWARD B RUSH LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2008
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 WAMPANOAG TRL
RIVERSIDE RI
02915-1504
US

IV. Provider business mailing address

610 WAMPANOAG TRL
RIVERSIDE RI
02915-1504
US

V. Phone/Fax

Practice location:
  • Phone: 401-274-2500
  • Fax:
Mailing address:
  • Phone: 401-431-9870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCSW00528
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW02158
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: