Provider Demographics
NPI:1588853790
Name:RUSH, STACY SUE (COTA/L)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:SUE
Last Name:RUSH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-3005
Mailing Address - Country:US
Mailing Address - Phone:229-894-6311
Mailing Address - Fax:
Practice Address - Street 1:322 MILLER RD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-3005
Practice Address - Country:US
Practice Address - Phone:229-894-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10399224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant