Healthcare Provider Details

I. General information

NPI: 1194485649
Provider Name (Legal Business Name): CORY RUBERTUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2021
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 COOK AVE
RATON NM
87740-3930
US

IV. Provider business mailing address

243 COOK AVE
RATON NM
87740-3930
US

V. Phone/Fax

Practice location:
  • Phone: 580-319-5770
  • Fax: 580-319-5770
Mailing address:
  • Phone: 580-319-5770
  • Fax: 580-319-7086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-77251
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-197599
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: