Healthcare Provider Details

I. General information

NPI: 1417906850
Provider Name (Legal Business Name): GLORIA DIANE RUTT PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GLORIA D. RUTT PSYD

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 COULTER DRIVE
CHEYENNE WY
82009
US

IV. Provider business mailing address

2305 COULTER DRIVE
CHEYENNE WY
82009
US

V. Phone/Fax

Practice location:
  • Phone: 307-286-4106
  • Fax: 307-632-6588
Mailing address:
  • Phone: 307-286-4106
  • Fax: 307-632-6588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number422
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: