Healthcare Provider Details

I. General information

NPI: 1760805956
Provider Name (Legal Business Name): LORI BETH RUDDICK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS LORI BETH ASHMORE

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N COLLEGE AVE
FAYETTEVILLE AR
72703-1944
US

IV. Provider business mailing address

1100 N COLLEGE AVE
FAYETTEVILLE AR
72703-1999
US

V. Phone/Fax

Practice location:
  • Phone: 479-443-4301
  • Fax:
Mailing address:
  • Phone: 479-443-4301
  • Fax: 479-587-5994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255R0406X
TaxonomyBlind Rehabilitation Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6790-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: