Provider Demographics
NPI:1699496364
Name:RUTAN, KATHY L (MSW)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:L
Last Name:RUTAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 LAKE AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5351
Mailing Address - Country:US
Mailing Address - Phone:260-207-4452
Mailing Address - Fax:
Practice Address - Street 1:2200 LAKE AVE STE 120
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5351
Practice Address - Country:US
Practice Address - Phone:260-207-4452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker