Provider Demographics
NPI:1043509060
Name:RUSK, GREGORY (LMT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:RUSK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 TWILIGHT TRL
Mailing Address - Street 2:SUITE 99B
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-8103
Mailing Address - Country:US
Mailing Address - Phone:972-523-0045
Mailing Address - Fax:
Practice Address - Street 1:508 TWILIGHT TRL
Practice Address - Street 2:SUITE 99B
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-8103
Practice Address - Country:US
Practice Address - Phone:972-523-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT112515225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist