Healthcare Provider Details

I. General information

NPI: 1639577943
Provider Name (Legal Business Name): SANDRA RUGGLES LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 LAKE COOK RD SUITE 220
DEERFIELD IL
60015
US

IV. Provider business mailing address

2622 HENRY ST
SHEBOYGAN WI
53081
US

V. Phone/Fax

Practice location:
  • Phone: 866-220-8371
  • Fax:
Mailing address:
  • Phone: 847-284-4001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180006623
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180006623
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: