Provider Demographics
NPI:1790978476
Name:RUSH, STACY LYN (COTA/L)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYN
Last Name:RUSH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 S LOOP 499
Mailing Address - Street 2:APT V8
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-2515
Mailing Address - Country:US
Mailing Address - Phone:309-303-8000
Mailing Address - Fax:
Practice Address - Street 1:902 S LOOP 499
Practice Address - Street 2:APT V8
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-2515
Practice Address - Country:US
Practice Address - Phone:309-303-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-25
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210607224Z00000X
IL057-002373224Z00000X
MO2007012402224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant