Basic Information
| Provider Information | |||||||||
| NPI: | 1366968075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUTHARDT | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 6610 QUAKER AVE | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067434270 | ||||||||
| FaxNumber: | 8067439097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2017 | ||||||||
| LastUpdateDate: | 05/08/2019 | ||||||||
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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 | 101Y00000X | 73921 | TX | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 73921 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.