Healthcare Provider Details

I. General information

NPI: 1447363015
Provider Name (Legal Business Name): KELLYANNE RUGENSTEIN PHD, LCSWR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WASHINGTON AVE
RENSSELAER NY
12144-1300
US

IV. Provider business mailing address

620 WASHINGTON AVE
RENSSELAER NY
12144-1300
US

V. Phone/Fax

Practice location:
  • Phone: 518-210-2486
  • Fax:
Mailing address:
  • Phone: 518-210-2486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number071634-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: