Healthcare Provider Details

I. General information

NPI: 1811096381
Provider Name (Legal Business Name): KIMBERLY ANN RURACK LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS KIMBERLY ANN DAMRON

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 W MAIN ST STE 201
BELLEVILLE IL
62223-1719
US

IV. Provider business mailing address

14 S 72ND ST
BELLEVILLE IL
62223-2321
US

V. Phone/Fax

Practice location:
  • Phone: 618-394-5900
  • Fax: 618-394-5909
Mailing address:
  • Phone: 618-398-1898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: