Provider Demographics
NPI:1306171814
Name:RUSH, SHANA J (PHD CCC-SLP)
Entity type:Individual
Prefix:DR
First Name:SHANA
Middle Name:J
Last Name:RUSH
Suffix:
Gender:F
Credentials:PHD CCC-SLP
Other - Prefix:DR
Other - First Name:SHANA
Other - Middle Name:J
Other - Last Name:ASBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:412 PLYMOUTH AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6028
Mailing Address - Country:US
Mailing Address - Phone:616-780-0590
Mailing Address - Fax:616-984-4559
Practice Address - Street 1:412 PLYMOUTH AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-6028
Practice Address - Country:US
Practice Address - Phone:616-780-0590
Practice Address - Fax:616-984-4559
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013545103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6301013545OtherCOMMERCIAL