MEDICARE: MISS LEAH RUTENBERG LCPC

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	180008086	IL

General Provider Information

NPI Number	:	1750556841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LEAH RUTENBERG LCPC

Provider Business Mailing Address
First Line	:	PO BOX 98
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-0098
Country	:	US
Telephone Number	:	618-710-4123
Fax Number	:	618-731-4082

Provider Business Practice Location Address
First Line	:	9 JUNCTION DR W
Second Line	:	SUITE 3
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-2931
Country	:	US
Telephone Number	:	618-710-4123
Fax Number	:	618-731-4082

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

Provider Enumeration Date	:	04/29/2008
Last Update Date	:	03/16/2017

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