Provider Demographics
NPI:1427621515
Name:RUSH, KELLY (LCSW-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RUSH
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 RESERVE GATE TER
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-5040
Mailing Address - Country:US
Mailing Address - Phone:484-678-1224
Mailing Address - Fax:
Practice Address - Street 1:10605 CONCORD ST STE 102
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2500
Practice Address - Country:US
Practice Address - Phone:301-962-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD191701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty