Provider Demographics
NPI:1639667173
Name:RUSCH, CARSON D
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:D
Last Name:RUSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1443 W 800 N STE 103
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2878
Mailing Address - Country:US
Mailing Address - Phone:801-655-4950
Mailing Address - Fax:
Practice Address - Street 1:4933 S 1500 W STE 110
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-7738
Practice Address - Country:US
Practice Address - Phone:801-820-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician