Healthcare Provider Details

I. General information

NPI: 1700325792
Provider Name (Legal Business Name): CANDE RUTHERFORD LLMSW, CAADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 HAZEN ST STE C
PAW PAW MI
49079-2008
US

IV. Provider business mailing address

3392 RIVERSIDE RD
BENTON HARBOR MI
49022-9527
US

V. Phone/Fax

Practice location:
  • Phone: 269-657-5574
  • Fax:
Mailing address:
  • Phone: 269-208-9392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801099930
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: