Basic Information
| Provider Information | |||||||||
| NPI: | 1760927909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSCH | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOSCA | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 175 E HAWTHORN PKWY | ||||||||
| Address2: | SUITE 235 | ||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600611463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16221 W 159TH ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | LOCKPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604417902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2016 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 178011536 | IL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 180.012962 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.