Healthcare Provider Details

I. General information

NPI: 1679208425
Provider Name (Legal Business Name): MANDY CHRISTINE RUCKMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2022
Last Update Date: 06/07/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 LONGLEAF CIR
ABERDEEN NC
28315-4575
US

IV. Provider business mailing address

135 LONGLEAF CIR
ABERDEEN NC
28315-4575
US

V. Phone/Fax

Practice location:
  • Phone: 631-223-8772
  • Fax:
Mailing address:
  • Phone: 360-918-2820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101683
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: