Provider Demographics
NPI:1427482199
Name:DE RUYTER, MARK ALAN (LMSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:DE RUYTER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E. 11TH ST.
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301
Mailing Address - Country:US
Mailing Address - Phone:712-264-6048
Mailing Address - Fax:
Practice Address - Street 1:116 E. 11TH ST.
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301
Practice Address - Country:US
Practice Address - Phone:712-264-6048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02160104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA02160OtherSOCIAL WORK LICENSE