Basic Information
| Provider Information | |||||||||
| NPI: | 1407989502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUTAN | ||||||||
| FirstName: | BRANDI | ||||||||
| MiddleName: | CELESTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COFFEY | ||||||||
| OtherFirstName: | BRANDI | ||||||||
| OtherMiddleName: | CELESTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1848 SE 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286926178 | ||||||||
| FaxNumber: | 8286922365 | ||||||||
| Practice Location | |||||||||
| Address1: | 571 S ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | FLAT ROCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286926178 | ||||||||
| FaxNumber: | 8283563998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | C009934 | NC | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 11720 | SC | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | C009934 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | CSW005851 | GA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | CSW005851 | 01 | GA | LICENSED CLINICAL SOCIAL WORKER | OTHER | 11720 | 01 | SC | LICENSED INDEPENDENT SOCIAL WORKER | OTHER | C009934 | 01 | NC | LICENSED CLINICAL SOCIAL WORKER | OTHER |