Provider Demographics
NPI:1063426575
Name:RUPPERT, PHILLIP PAUL (PSYD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:PAUL
Last Name:RUPPERT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 LAUREL MANOR DR
Mailing Address - Street 2:BLDG. 240
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-5603
Mailing Address - Country:US
Mailing Address - Phone:352-391-1220
Mailing Address - Fax:352-391-9247
Practice Address - Street 1:3309 WEDGEWOOD LN
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-7177
Practice Address - Country:US
Practice Address - Phone:352-391-1220
Practice Address - Fax:352-391-9247
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1057057103T00000X
WI1057103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39045600Medicaid
WI001444285Medicare ID - Type Unspecified