Provider Demographics
NPI:1720436231
Name:HART RUTHENBECK, PAUL DAVID (LADC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:DAVID
Last Name:HART RUTHENBECK
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:DAVID
Other - Last Name:RUTHENBECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 DIVISION ST S
Mailing Address - Street 2:SUITE A
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-2095
Mailing Address - Country:US
Mailing Address - Phone:507-664-9407
Mailing Address - Fax:507-664-3862
Practice Address - Street 1:401 DIVISION ST S
Practice Address - Street 2:SUITE A
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-2095
Practice Address - Country:US
Practice Address - Phone:507-664-9407
Practice Address - Fax:507-664-3862
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303259101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)