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General NPI Number Information
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NPI Number | 1639080211
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Entity Type | Individual
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Provider Name | KIRSTEN RENEE RUCKER
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Gender | Female
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Dates
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Enumeration Date | 09/14/2026
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Last Update Date | 09/14/2026
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Provider Practice Location Address
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Address Line | 515 W SW LOOP 323
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City | TYLER
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State | TX
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Zip | 75701-9455
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Country | US
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Telephone | 903-402-3822
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1245
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City | VAN
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State | TX
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Zip | 75790-1245
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Country | US
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Telephone |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 94459
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License Number State | TX
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