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General NPI Number Information
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NPI Number | 1669795761
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Entity Type | Organization
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Legal Business Name | DR. LAURIE FAIRALL-RUETER, LLC
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Dates
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Enumeration Date | 03/04/2010
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Last Update Date | 04/17/2014
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Provider Practice Location Address
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Address Line | 4400 MARSH LANDING BLVD SUITE 1
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-1287
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Country | US
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Telephone | 904-463-2284
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Fax | 904-543-7755
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Provider Business Mailing Address
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Address Line | 4400 MARSH LANDING BLVD SUITE 1
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-1287
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Country | US
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Telephone | 904-463-2284
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Fax | 904-543-7755
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. LAURIE FAIRALL-RUETER
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Credential | PSY.D.
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Telephone | 904-463-2284
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 36593
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY003739
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License Number State | GA
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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 | PY 7675
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License Number State | FL
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