Healthcare Provider Details

I. General information

NPI: 1760127286
Provider Name (Legal Business Name): KATHLEEN RUZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 MAIN ST
MELROSE PARK IL
60160-3902
US

IV. Provider business mailing address

1414 MAIN ST
MELROSE PARK IL
60160-3902
US

V. Phone/Fax

Practice location:
  • Phone: 708-681-0073
  • Fax: 708-681-3958
Mailing address:
  • Phone: 708-681-0073
  • Fax: 708-681-3958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberNPPES
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: