Basic Information
| Provider Information | |||||||||
| NPI: | 1518209196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSH | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1550 N CRESTMONT DR | ||||||||
| Address2: | STE A | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082884200 | ||||||||
| FaxNumber: | 2082884279 | ||||||||
| Practice Location | |||||||||
| Address1: | 1550 N CRESTMONT DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082884200 | ||||||||
| FaxNumber: | 2082884279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2013 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | 1268A | ID | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 363LP0808X | NP1268A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163WP0808X | N-25920 | ID | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 12644208 | 01 | ID | CAQH | OTHER | 1992858500 | 05 | ID | MEDICAID |