Provider Demographics
NPI:1528154358
Name:TRACEY RUSIN, DOROTHY A (PH D)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:A
Last Name:TRACEY RUSIN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20001 BUCKLODGE RD
Mailing Address - Street 2:
Mailing Address - City:BOYDS
Mailing Address - State:MD
Mailing Address - Zip Code:20841
Mailing Address - Country:US
Mailing Address - Phone:301-977-0150
Mailing Address - Fax:
Practice Address - Street 1:9077 SHADY GROVE COURT
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877
Practice Address - Country:US
Practice Address - Phone:301-977-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD925103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
491593Medicare ID - Type Unspecified