Provider Demographics
NPI:1992264113
Name:RUSH, TYRENNA INIKA
Entity type:Individual
Prefix:
First Name:TYRENNA
Middle Name:INIKA
Last Name:RUSH
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 1:10608 BELLA VISTA DR APT 9204
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-3133
Mailing Address - Country:US
Mailing Address - Phone:765-717-7268
Mailing Address - Fax:
Practice Address - Street 1:10608 BELLA VISTA DR APT 9204
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-3133
Practice Address - Country:US
Practice Address - Phone:765-717-7268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty