Provider Demographics
NPI:1114075637
Name:RUSH, CYNTHIA POTTER (MA, HSP)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:POTTER
Last Name:RUSH
Suffix:
Gender:F
Credentials:MA, HSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 GULF SHORE DR UNIT 8238
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5424
Mailing Address - Country:US
Mailing Address - Phone:615-579-4985
Mailing Address - Fax:
Practice Address - Street 1:223 CODY AVE BLDG 90310
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5302
Practice Address - Country:US
Practice Address - Phone:850-884-8032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000011297103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical