Healthcare Provider Details

I. General information

NPI: 1700412053
Provider Name (Legal Business Name): AMANDA FRUDAKIS-RUCKEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 WEHRLI RD
LONG VALLEY NJ
07853-3418
US

IV. Provider business mailing address

15 WEHRLI RD
LONG VALLEY NJ
07853-3418
US

V. Phone/Fax

Practice location:
  • Phone: 631-764-9261
  • Fax:
Mailing address:
  • Phone: 631-764-9261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05919200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: