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General NPI Number Information
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NPI Number | 1477962173
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Entity Type | Individual
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Provider Name | SAMUEL EMILE RUTHERFORD DR.
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Gender | Male
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Dates
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Enumeration Date | 08/06/2014
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Last Update Date | 08/19/2024
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Provider Practice Location Address
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Address Line | 1481 W 10TH ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46202-2803
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Country | US
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Telephone | 317-544-0000
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Fax |
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Provider Business Mailing Address
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Address Line | 1255 PEARL ST STE 101
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City | EUGENE
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State | OR
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Zip | 97401-3570
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Country | US
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Telephone | 541-799-5386
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | T-16-097
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 20043782B
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License Number State | IN
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