Provider Demographics
NPI:1346767860
Name:RUSH, MANDY KORINNE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:KORINNE
Last Name:RUSH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 PEACHTREE LN
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-2112
Mailing Address - Country:US
Mailing Address - Phone:865-919-7872
Mailing Address - Fax:
Practice Address - Street 1:1204 FRYE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3052
Practice Address - Country:US
Practice Address - Phone:423-745-0434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2876224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant