Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist | 01078 | GA |
NPI | 1649349689 |
---|---|
Provider Name | Dr. Michele Jean Rusin |
First Address | Atlanta, GA 30333-3207 |
Second Address | Decatur, GA 30033-3506 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2006 |
Last Update Date | 17/01/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
R74310 | (02) | GA |