Healthcare Provider Details

I. General information

NPI: 1396551685
Provider Name (Legal Business Name): RUTH IRADUKUNDA MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 11/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 N GREEN BAY AVE UPPR LEVEL
GLENDALE WI
53209-3811
US

IV. Provider business mailing address

6025 N GREEN BAY AVE UPPR LEVEL
GLENDALE WI
53209-3811
US

V. Phone/Fax

Practice location:
  • Phone: 414-247-0801
  • Fax:
Mailing address:
  • Phone: 414-247-0801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number135223
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: