Healthcare Provider Details

I. General information

NPI: 1407153497
Provider Name (Legal Business Name): MISS ROBYN MICHELLE RUTAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 02/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E HURON ST UNIT 1106
CHICAGO IL
60611-2766
US

IV. Provider business mailing address

30 E HURON ST UNIT 1106
CHICAGO IL
60611-2766
US

V. Phone/Fax

Practice location:
  • Phone: 765-341-4580
  • Fax:
Mailing address:
  • Phone: 765-341-4580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number3898838310
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: