Provider Demographics
NPI:1912199241
Name:RUSH, PATRICIA DIANE
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DIANE
Last Name:RUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 BRYAN ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5958
Mailing Address - Country:US
Mailing Address - Phone:321-409-2136
Mailing Address - Fax:321-409-2140
Practice Address - Street 1:2202 BRYAN ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5958
Practice Address - Country:US
Practice Address - Phone:321-409-2136
Practice Address - Fax:321-409-2140
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7685904 00Medicaid