Provider Demographics
NPI:1972878494
Name:RUTLEDGE, NICHOLAS (MSW)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:RUTLEDGE
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:LEAKESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39451-5622
Mailing Address - Country:US
Mailing Address - Phone:228-374-2494
Mailing Address - Fax:
Practice Address - Street 1:96 MIKE RUTLEDGE RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:MS
Practice Address - Zip Code:39455-7605
Practice Address - Country:US
Practice Address - Phone:202-309-7982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC81051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS294821YR8UMedicare PIN