Provider Demographics
NPI:1114055274
Name:RUSH, MEMORY LEE (MSW)
Entity Type:Individual
Prefix:MS
First Name:MEMORY
Middle Name:LEE
Last Name:RUSH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6097
Mailing Address - Country:US
Mailing Address - Phone:707-822-4558
Mailing Address - Fax:
Practice Address - Street 1:261 E 11TH ST
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6097
Practice Address - Country:US
Practice Address - Phone:707-822-4558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 234141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical