Healthcare Provider Details

I. General information

NPI: 1780645382
Provider Name (Legal Business Name): SUSAN ANNETTE RUTLEDGE MED LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11155 DUNN RD SUITE 312E
SAINT LOUIS MO
63136-6150
US

IV. Provider business mailing address

11155 DUNN RD STE 312E
SAINT LOUIS MO
63136-6111
US

V. Phone/Fax

Practice location:
  • Phone: 314-953-8500
  • Fax: 314-355-1070
Mailing address:
  • Phone: 314-953-8500
  • Fax: 314-355-1070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number003196
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: