=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487091658
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMILY BARR RUTH, PSYD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2013
-----------------------------------------------------
Last Update Date | 05/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 702 N BLACKHAWK AVE SUITE 209
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53705-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-669-7981
-----------------------------------------------------
Fax | 608-441-3370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 N BLACKHAWK AVE SUITE 209
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53705-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-669-7981
-----------------------------------------------------
Fax | 608-441-3370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEMBER
-----------------------------------------------------
Name | DR. EMILY BARR RUTH
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 608-669-7981
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 2804-57
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------