MEDICARE: LEILA RUCKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	76171	TX

General Provider Information

NPI Number	:	1467052936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEILA RUCKER

Provider Business Mailing Address
First Line	:	4830 FAIR OAK DALE LN
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77346-1866
Country	:	US
Telephone Number	:	281-536-7856
Fax Number	:

Provider Business Practice Location Address
First Line	:	4830 FAIR OAK DALE LN
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77346-1866
Country	:	US
Telephone Number	:	281-536-7856
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2020
Last Update Date	:	10/26/2020

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Directions to “ LEILA RUCKER ” Practice Location

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