Provider Demographics
NPI:1578997441
Name:RUSH-WILSON, TIFFANY CANDYCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:CANDYCE
Last Name:RUSH-WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29525 CHAGRIN BLVD
Mailing Address - Street 2:313
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4644
Mailing Address - Country:US
Mailing Address - Phone:216-316-8265
Mailing Address - Fax:
Practice Address - Street 1:29525 CHAGRIN BLVD
Practice Address - Street 2:313
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4644
Practice Address - Country:US
Practice Address - Phone:216-316-8265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0003341101YP2500X
OH6457103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist