Provider Demographics
NPI:1356419790
Name:RUSH, LARONTA UPSON (PHD)
Entity type:Individual
Prefix:
First Name:LARONTA
Middle Name:UPSON
Last Name:RUSH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LARONTA
Other - Middle Name:M
Other - Last Name:UPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:3760 LAVISTA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5622
Mailing Address - Country:US
Mailing Address - Phone:770-375-8124
Mailing Address - Fax:770-559-5543
Practice Address - Street 1:3760 LAVISTA RD STE 102
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5622
Practice Address - Country:US
Practice Address - Phone:770-375-8124
Practice Address - Fax:770-559-5543
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003025103T00000X, 103TS0200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA636448495EMedicaid