Basic Information
| Provider Information | |||||||||
| NPI: | 1396166013 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUHLAND | ||||||||
| FirstName: | CONSTANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 MARIKA RD | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997095521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074740890 | ||||||||
| FaxNumber: | 9074743621 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E DANNA AVE | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996546422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073577519 | ||||||||
| FaxNumber: | 9073577569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2013 | ||||||||
| LastUpdateDate: | 12/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YS0200X | N | Behavioral Health & Social Service Providers | Counselor | School |
ID Information
| ID | Type | State | Issuer | Description | MH3237 | 05 | AK | MEDICAID |