Provider Demographics
NPI:1437415718
Name:RUSH, CHARLA ANN
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:ANN
Last Name:RUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 KIETZKE LN
Mailing Address - Street 2:B114
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-5033
Mailing Address - Country:US
Mailing Address - Phone:775-848-8834
Mailing Address - Fax:
Practice Address - Street 1:545 W SIERRA ST
Practice Address - Street 2:
Practice Address - City:PORTOLA
Practice Address - State:CA
Practice Address - Zip Code:96122-8615
Practice Address - Country:US
Practice Address - Phone:775-848-8834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV274C101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)