MEDICARE: MARK R DERUITER MA, LLMFT

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	106H00000X	Marriage & Family Therapist	4101006710	MI

General Provider Information

NPI Number	:	1902340136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK R DERUITER MA, LLMFT

Provider Business Mailing Address
First Line	:	778 COLUMBIA AVE W
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49015-3028
Country	:	US
Telephone Number	:	269-965-3247
Fax Number	:	269-966-4135

Provider Business Practice Location Address
First Line	:	778 COLUMBIA AVE W
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49015-3028
Country	:	US
Telephone Number	:	269-965-3247
Fax Number	:	269-966-4135

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

Provider Enumeration Date	:	12/07/2016
Last Update Date	:	12/07/2016

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