Healthcare Provider Details

I. General information

NPI: 1376406041
Provider Name (Legal Business Name): TERRELL MONTAE RUSH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 WYOMING ST
CHARLESTON WV
25302-1813
US

IV. Provider business mailing address

607 WYOMING ST
CHARLESTON WV
25302-1813
US

V. Phone/Fax

Practice location:
  • Phone: 681-945-4255
  • Fax:
Mailing address:
  • Phone: 681-945-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberAP00946220
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: