Basic Information
Provider Information | |||||||||
NPI: | 1932376530 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUTKOWSKI | ||||||||
FirstName: | AUBREY | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JPHNSTON | ||||||||
OtherFirstName: | AUBREY | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LMSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2647 SATURN DR | ||||||||
Address2: |   | ||||||||
City: | LAKE ORION | ||||||||
State: | MI | ||||||||
PostalCode: | 483601736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5864803636 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 42669 GARFIELD RD | ||||||||
Address2: |   | ||||||||
City: | CLINTON TWP | ||||||||
State: | MI | ||||||||
PostalCode: | 480385036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5864125321 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2008 | ||||||||
LastUpdateDate: | 03/04/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | L1244192 | MI | Y |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | L1244192 | MI | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041S0200X | L1244192 | MI | N |   | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.