Provider Demographics
NPI:1093197089
Name:RUST, THERESA LYNN (PCC-S, LSW, LICDC-CS)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LYNN
Last Name:RUST
Suffix:
Gender:F
Credentials:PCC-S, LSW, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1684
Mailing Address - Country:US
Mailing Address - Phone:513-475-2702
Mailing Address - Fax:
Practice Address - Street 1:6950 COLUMBIA GATEWAY DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2706
Practice Address - Country:US
Practice Address - Phone:513-797-7031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH981323101YA0400X
OHS 0019424104100000X
OHE 0004070 SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker