Provider Demographics
NPI:1528765310
Name:RUEBENSAM, BRENT ALLEN (, MA, LPC, ASOTP)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:ALLEN
Last Name:RUEBENSAM
Suffix:
Gender:M
Credentials:, MA, LPC, ASOTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 63RD ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-5819
Mailing Address - Country:US
Mailing Address - Phone:312-560-4874
Mailing Address - Fax:
Practice Address - Street 1:2511 63RD ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-5819
Practice Address - Country:US
Practice Address - Phone:312-560-4874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX85943101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional