MEDICARE: DR. TIFFANY CANDYCE RUSH-WILSON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	E0003341	OH
2	103T00000X	Psychologist	6457	OH

General Provider Information

NPI Number	:	1578997441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIFFANY CANDYCE RUSH-WILSON PH.D.

Provider Business Mailing Address
First Line	:	29525 CHAGRIN BLVD
Second Line	:	313
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-4644
Country	:	US
Telephone Number	:	216-316-8265
Fax Number	:

Provider Business Practice Location Address
First Line	:	29525 CHAGRIN BLVD
Second Line	:	313
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-4644
Country	:	US
Telephone Number	:	216-316-8265
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2013
Last Update Date	:	08/28/2013

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