MEDICARE: DR. LAURIE FAIRALL-RUETER, LLC

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	103TC0700X	Clinical Psychologist	36593	TX
2	103TC0700X	Clinical Psychologist	PY003739	GA
3	103TC0700X	Clinical Psychologist	PY 7675	FL

General Provider Information

NPI Number	:	1669795761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. LAURIE FAIRALL-RUETER, LLC

Provider Business Mailing Address
First Line	:	4400 MARSH LANDING BLVD
Second Line	:	SUITE 1
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-1287
Country	:	US
Telephone Number	:	904-463-2284
Fax Number	:	904-543-7755

Provider Business Practice Location Address
First Line	:	4400 MARSH LANDING BLVD
Second Line	:	SUITE 1
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-1287
Country	:	US
Telephone Number	:	904-463-2284
Fax Number	:	904-543-7755

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	DR. LAURIE FAIRALL-RUETER
Credential	:	PSY.D.
Telephone Number	:	904-463-2284

Provider Enumeration Date	:	03/04/2010
Last Update Date	:	04/17/2014

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