Provider Demographics
NPI:1679099873
Name:RUSH, LEVI CHARLES
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:CHARLES
Last Name:RUSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:LEVI
Other - Last Name:RUSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6626 CLOVIS CT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-4573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6626 CLOVIS CT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78233-4573
Practice Address - Country:US
Practice Address - Phone:806-341-4665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61280104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker