Healthcare Provider Details

I. General information

NPI: 1972083319
Provider Name (Legal Business Name): ANNA RUGER LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MEGHAN LN
JUDSONIA AR
72081-9302
US

IV. Provider business mailing address

120 MEGHAN LN
JUDSONIA AR
72081-9302
US

V. Phone/Fax

Practice location:
  • Phone: 501-729-4479
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1706225
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: