Healthcare Provider Details

I. General information

NPI: 1053242164
Provider Name (Legal Business Name): RANDALL W RUTHERFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 E SPEEDWAY BLVD STE 118
TUCSON AZ
85719-4750
US

IV. Provider business mailing address

4109 E SUNRISE DR APT 1504
TUCSON AZ
85718
US

V. Phone/Fax

Practice location:
  • Phone: 520-268-4609
  • Fax:
Mailing address:
  • Phone: 520-268-4609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLIAC-155415
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: