Provider Demographics
NPI:1740997477
Name:RUSH PEDIATRIC NEUROPSYCHOLOGY, PLLC
Entity type:Organization
Organization Name:RUSH PEDIATRIC NEUROPSYCHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:616-780-0590
Mailing Address - Street 1:412 PLYMOUTH AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6028
Mailing Address - Country:US
Mailing Address - Phone:616-780-0590
Mailing Address - Fax:616-984-4559
Practice Address - Street 1:412 PLYMOUTH AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-6028
Practice Address - Country:US
Practice Address - Phone:616-780-0590
Practice Address - Fax:616-984-4559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-02
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty