Healthcare Provider Details

I. General information

NPI: 1568882140
Provider Name (Legal Business Name): ULA SKY RUTAN M.A., LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE SUITE 300
JACKSON MI
49202-2179
US

IV. Provider business mailing address

PO BOX 81
SOMERSET CENTER MI
49282-0081
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-1234
  • Fax:
Mailing address:
  • Phone: 517-921-8627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014169
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: