Healthcare Provider Details

I. General information

NPI: 1427641760
Provider Name (Legal Business Name): NICOLE RERUCHA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 N 140TH AVE
GOODYEAR AZ
85395-2437
US

IV. Provider business mailing address

7427 W HILL LN
GLENDALE AZ
85310-5627
US

V. Phone/Fax

Practice location:
  • Phone: 602-692-2526
  • Fax:
Mailing address:
  • Phone: 602-692-2526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC19228
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: