Provider Demographics
NPI:1215155973
Name:O'LEARY, RUSTY
Entity type:Individual
Prefix:
First Name:RUSTY
Middle Name:
Last Name:O'LEARY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:
Other - Last Name:O'LEARY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:1305 2ND ST S
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3944
Mailing Address - Country:US
Mailing Address - Phone:208-463-0202
Mailing Address - Fax:208-463-0205
Practice Address - Street 1:1305 2ND ST S
Practice Address - Street 2:SUITE 201
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3944
Practice Address - Country:US
Practice Address - Phone:208-463-0202
Practice Address - Fax:208-463-0205
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-296101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCPC-296OtherID PROFESSIONAL LICENSE