MEDICARE: RUTHIE LEE STARK - REDMAN LCDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	14743	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	101Y00000X	OTHER	TX	M.S. ADDICTION COUNSELOR

General Provider Information

NPI Number	:	1912538547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUTHIE LEE STARK - REDMAN LCDC

Provider Business Mailing Address
First Line	:	9001 GLACIER AVE APT 226
Second Line	:
City	:	TEXAS CITY
State	:	TX
Zip	:	77591-3017
Country	:	US
Telephone Number	:	440-231-7096
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 NASA PWKY
Second Line	:	SUITE 201 A
City	:	HOUSTON
State	:	TX
Zip	:	77598-7759
Country	:	US
Telephone Number	:	281-904-6512
Fax Number	:

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

Provider Enumeration Date	:	02/02/2020
Last Update Date	:	07/24/2022

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