Healthcare Provider Details

I. General information

NPI: 1417782962
Provider Name (Legal Business Name): JUSTINE ROSE RUEGG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MIDDLE RINCON RD
SANTA ROSA CA
95409-3107
US

IV. Provider business mailing address

518 WILSON ST
SANTA ROSA CA
95401-6247
US

V. Phone/Fax

Practice location:
  • Phone: 707-335-0702
  • Fax:
Mailing address:
  • Phone: 415-715-7922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: