Provider Demographics
NPI:1619008091
Name:RUSH, BRUCE A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:RUSH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-1652
Mailing Address - Country:US
Mailing Address - Phone:310-453-6251
Mailing Address - Fax:310-734-1682
Practice Address - Street 1:1112 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-1652
Practice Address - Country:US
Practice Address - Phone:310-453-6251
Practice Address - Fax:310-734-1682
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17799103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical