Healthcare Provider Details

I. General information

NPI: 1215752944
Provider Name (Legal Business Name): INGRID RAUK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 E ADAMS ST
SYRACUSE NY
13210-2576
US

IV. Provider business mailing address

150 SIMS DR
SYRACUSE NY
13244-1359
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-5240
  • Fax:
Mailing address:
  • Phone: 517-862-8501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301019455
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number026464
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: