Provider Demographics
NPI:1629628284
Name:RUSHTON, BROOKE T (CBRS)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:T
Last Name:RUSHTON
Suffix:
Gender:F
Credentials:CBRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:2201 IRONWOOD PL STE 100
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2670
Practice Address - Country:US
Practice Address - Phone:208-769-4222
Practice Address - Fax:844-803-7399
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID172V00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCC232146AOtherLICENSE