Provider Demographics
NPI:1467738328
Name:BRUSH, CYNTHIA O
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:O
Last Name:BRUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:CYNTHIA
Other - Middle Name:O
Other - Last Name:SENGBOUNOUVONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 PARKVIEW AVE
Mailing Address - Street 2:CREDENTIALING S200C
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1822
Mailing Address - Country:US
Mailing Address - Phone:815-395-5861
Mailing Address - Fax:815-395-5575
Practice Address - Street 1:1221 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2231
Practice Address - Country:US
Practice Address - Phone:815-972-1000
Practice Address - Fax:815-972-1086
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490224911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical