MEDICARE: ROSEANNA RUTLEDGE, LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH3166	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z7891	OTHER		BCBS

General Provider Information

NPI Number	:	1427412873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSEANNA RUTLEDGE, LMHC

Provider Business Mailing Address
First Line	:	1208 NW 6TH ST
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32601-4245
Country	:	US
Telephone Number	:	352-379-2829
Fax Number	:	352-379-2843

Provider Business Practice Location Address
First Line	:	1208 NW 6TH ST
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32601-4245
Country	:	US
Telephone Number	:	352-379-2829
Fax Number	:	352-379-2843

Authorized Official
Title or Position	:	OWNER
Name	:	ROSEANNA RUTLEDGE
Credential	:
Telephone Number	:	352-379-2829

Provider Enumeration Date	:	04/12/2016
Last Update Date	:	04/12/2016

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