Provider Demographics
NPI:1386345973
Name:RUSHTON, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:RUSHTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 UNION AVE APT A
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-4237
Mailing Address - Country:US
Mailing Address - Phone:409-497-3272
Mailing Address - Fax:
Practice Address - Street 1:1101 S WINCHESTER BLVD STE J205
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3918
Practice Address - Country:US
Practice Address - Phone:408-404-5443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132675106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist