Provider Demographics
NPI:1568863447
Name:DUSH, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DUSH
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 1:1211 W LIMA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:KENTON
Mailing Address - State:OH
Mailing Address - Zip Code:43326-8846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1211 W LIMA ST
Practice Address - Street 2:SUITE A
Practice Address - City:KENTON
Practice Address - State:OH
Practice Address - Zip Code:43326-8846
Practice Address - Country:US
Practice Address - Phone:419-674-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3129745174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH70604895Medicaid