Provider Demographics
NPI:1679115612
Name:RUSH, REBECCA JENAE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JENAE
Last Name:RUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:JENAE
Other - Last Name:BANNASCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1939 S DIVISION AVE.
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507
Mailing Address - Country:US
Mailing Address - Phone:616-247-3815
Mailing Address - Fax:
Practice Address - Street 1:1939 S DIVISION AVE.
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507
Practice Address - Country:US
Practice Address - Phone:616-247-3815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI82299225800000X, 225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist