Provider Demographics
NPI:1215675020
Name:RUTKOWSKI, CODY NEAL (CDCA)
Entity type:Individual
Prefix:MR
First Name:CODY
Middle Name:NEAL
Last Name:RUTKOWSKI
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4307
Mailing Address - Country:US
Mailing Address - Phone:419-740-5079
Mailing Address - Fax:
Practice Address - Street 1:4747 MONROE ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4307
Practice Address - Country:US
Practice Address - Phone:419-740-5079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.179899101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000OtherI DON'T HAVE A MEDICAID NUMBER AT THIS TIME