Basic Information
| Provider Information | |||||||||
| NPI: | 1790403780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUTKOWSKI | ||||||||
| FirstName: | ELLY | ||||||||
| MiddleName: | KUMIKO BASIA | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 WOODRUFF PLACE EAST DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462011917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176072600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4090 BRIARGATE PKWY | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193051234 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2022 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.