Provider Demographics
NPI:1104670694
Name:RUSH, BON J (LSAA)
Entity type:Individual
Prefix:
First Name:BON
Middle Name:J
Last Name:RUSH
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:212 SUNNY SLOPE DR
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-7258
Mailing Address - Country:US
Mailing Address - Phone:940-231-4929
Mailing Address - Fax:
Practice Address - Street 1:107 SUNSET LOOP
Practice Address - Street 2:
Practice Address - City:MESCALERO
Practice Address - State:NM
Practice Address - Zip Code:88340
Practice Address - Country:US
Practice Address - Phone:575-464-2827
Practice Address - Fax:575-464-4321
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2023-0647101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)