Healthcare Provider Details

I. General information

NPI: 1033422605
Provider Name (Legal Business Name): DR. CHERYL ANN RUTHERFORD-NGOTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6702 TREEHILLS PKWY
STONE MOUNTAIN GA
30088-4605
US

IV. Provider business mailing address

PO BOX 941692
ATLANTA GA
31141-0692
US

V. Phone/Fax

Practice location:
  • Phone: 404-914-1777
  • Fax:
Mailing address:
  • Phone: 404-914-1777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number107031
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number107031
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: