Provider Demographics
NPI:1699969139
Name:RUBLAITUS, CYNTHIA (LCSW)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:RUBLAITUS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BOARDWALK SPRINGS PL
Mailing Address - Street 2:SUITE 111
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-4778
Mailing Address - Country:US
Mailing Address - Phone:636-695-4554
Mailing Address - Fax:
Practice Address - Street 1:ONE MEMORIAL DRIVE
Practice Address - Street 2:SENIOR RENEWAL PROGRAM-OLIN WING
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6722
Practice Address - Country:US
Practice Address - Phone:618-463-7518
Practice Address - Fax:618-463-7896
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0114561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215867Medicare PIN