Provider Demographics
NPI:1114222320
Name:RUSK, ILENE NAOMI (PHD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:NAOMI
Last Name:RUSK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 BROADWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-4240
Mailing Address - Country:US
Mailing Address - Phone:303-938-9244
Mailing Address - Fax:303-413-1308
Practice Address - Street 1:2523 BROADWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-4240
Practice Address - Country:US
Practice Address - Phone:303-938-9244
Practice Address - Fax:303-413-1308
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7079103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation