Basic Information
| Provider Information | |||||||||
| NPI: | 1184006421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANTASSELL | ||||||||
| FirstName: | RUTH | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AGLA | ||||||||
| OtherFirstName: | RUTH | ||||||||
| OtherMiddleName: | V. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1726 BUCKLEY LN | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846065031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013736562 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1726 BUCKLEY LN | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846065031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013736562 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2015 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.