Provider Demographics
NPI:1598026817
Name:BAILEY-RUTLEDGE, MARY J (MS, LPC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:J
Last Name:BAILEY-RUTLEDGE
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 GILLIS ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-5819
Mailing Address - Country:US
Mailing Address - Phone:325-655-5774
Mailing Address - Fax:325-655-8553
Practice Address - Street 1:79 GILLIS ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5819
Practice Address - Country:US
Practice Address - Phone:325-655-5774
Practice Address - Fax:325-655-8553
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16247101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1760522411Medicaid