Provider Demographics
NPI:1720771900
Name:RUSH, MIKAYLA NICOLE (LLC)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:NICOLE
Last Name:RUSH
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SOUTHERN ACRES DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-3766
Mailing Address - Country:US
Mailing Address - Phone:616-560-4356
Mailing Address - Fax:
Practice Address - Street 1:170 COLLEGE AVE STE 310
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-2982
Practice Address - Country:US
Practice Address - Phone:616-426-9034
Practice Address - Fax:616-404-4103
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022901101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional