Provider Demographics
NPI:1053799015
Name:RUSCH, DANA (PHD)
Entity type:Individual
Prefix:DR
First Name:DANA
Middle Name:
Last Name:RUSCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2819 W CORTEZ ST
Mailing Address - Street 2:APT 3E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-6985
Mailing Address - Country:US
Mailing Address - Phone:773-339-5159
Mailing Address - Fax:
Practice Address - Street 1:1747 W ROOSEVELT RD
Practice Address - Street 2:INSTITUTE FOR JUVENILE RESEARCH, COLBETH CLINIC
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1264
Practice Address - Country:US
Practice Address - Phone:312-996-7723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008927103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent