Healthcare Provider Details

I. General information

NPI: 1699217604
Provider Name (Legal Business Name): DEBORAH RENE RUYMAN MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 6TH AVENUE CT NE
ISANTI MN
55040-3208
US

IV. Provider business mailing address

904 6TH AVENUE CT NE
ISANTI MN
55040-3208
US

V. Phone/Fax

Practice location:
  • Phone: 763-444-7556
  • Fax: 763-434-0192
Mailing address:
  • Phone: 763-444-7556
  • Fax: 763-434-0192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18875
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: