Provider Demographics
NPI:1215291356
Name:RUTHERFORD, MEGHANN ANTONIAN (LLMSW)
Entity type:Individual
Prefix:MS
First Name:MEGHANN
Middle Name:ANTONIAN
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 WOODSLEE DR
Mailing Address - Street 2:#407
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-4401
Mailing Address - Country:US
Mailing Address - Phone:810-955-6640
Mailing Address - Fax:
Practice Address - Street 1:26184 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2084
Practice Address - Country:US
Practice Address - Phone:313-389-7525
Practice Address - Fax:313-389-7510
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010944471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical