Provider Demographics
NPI:1497952386
Name:RUSH, SUBRINA LEONTINE (LPC)
Entity Type:Individual
Prefix:MS
First Name:SUBRINA
Middle Name:LEONTINE
Last Name:RUSH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6326 ELLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-5025
Mailing Address - Country:US
Mailing Address - Phone:678-622-7973
Mailing Address - Fax:
Practice Address - Street 1:5300 MEMORIAL DR
Practice Address - Street 2:224F
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3148
Practice Address - Country:US
Practice Address - Phone:678-622-7973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004530101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional